Staying on top of fraud is all about investigation by the employer. Don't be intimidated. As you know, many, many examples of all kinds of clever schemes, plans, ideas and criminal behavior are presented in the WCK Blog. Employers cannot be TOO aware of the lengths a dishonest worker may go to. And, employees cannot be TOO aware of the employer's intention to pursue all suspicious workers' compensation claims vigorously. It costs a lot less to find, investigate and stop fraud and abuse then to let it go on. A Case Study A California parks worker was apprehended as the result of an investigation conducted by the California Department of Insurance (CDI) and charged with presenting a false or fraudulent insurance claim and making false or fraudulent statements to his employer and to his treating physicians. Over a five-year period, the man reportedly told his treating and evaluating doctors: 1. He was unemployed. 2. His injury continued to worsen. 3. He could not walk or walked with great difficulty, pain and limping, even after surgery to repair the injury. 4. He made similar statements under oath during a deposition taken when he filed for workers' compensation. What an Investigation Found 1. Undercover surveillance video captured the individual walking normally and bearing weight on his left ankle with no indications of pain. 2. He was videoed performing work-related activities at an auto-repair shop. 3. He made inconsistent statements and material misrepresentations regarding the severity of his industrial injury and his employment status during appointments with physicians treating and/or evaluating him. 4. These inconsistencies were found in his sworn testimony in a deposition for the purpose of filing a false workers' comp insurance claim with the employer's third-party administrator. 5. He was receiving workers' compensation benefits. Cost to the Employer – A Whopping +/-$170,000 $38,200 in indemnity benefits $23,300 in temporary total disability benefits $14,800 in permanent disability benefits $38,500 in medical treatment $ 3,600 in vocational rehabilitation benefits $50,400 in legal expenses, defense costs and surveillance/investigation A conviction will results in five years in prison and/or $10,000 in fines for each count. Oh, and by the way: What was the injury? He "rolled" his left ankle while painting lines at a tennis court in a city-owned park.
Is anyone asking why it took FIVE YEARS to bring this worker to justice?
Author Robert Elliott, senior vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers' Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: [email protected] or 860-786-8286.
WC Best Practices Quick Check: http://www.workerscompkit.com/intro/ Workers' Comp Kit Books & Guides: http://www.reduceyourworkerscomp.com/workers-comp-books-manuals.php Do not use this information without independent verification. All state laws vary.
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