4 Proofs Fraud Can Come from Any Employee

An employer will always know a lot about her employees. Depending on the size of your shop, the boss sees her workers every workday. She talks to them about their weekends. She asks about their kids and families. Over time one really can find out a lot about employees.

You may think it is only the “bad” employees who get injured or complain about being injured at work — that they are the ones filing the claims and making a big deal about being sore at the end of the day – you are probably wrong. The complainers aren’t always the ones to watch out for.

Not exactly. An adjuster will tell you often it is “good” employees who can pull off a bad claim and make it stick. After all, they know exactly what to say, who to say it to, and what to do after alleging an injury. Most often a “good” employee is the one who knows how to work the system. So, the lesson here is to watch out for ALL injuries. Here are some ways employees can fool you and the adjuster:

1. They know what symptoms to report:

Any employee of more than a year can pose a threat. They have been around long enough to see a other employees get hurt, make a claim, get some time off, and try to get their claim accepted. Most often, going on work comp is not as glamorous as it seems. It can really be more bothersome to a person’s daily routine. After all, you get less money, you miss time from work, you lose out on personal time as you go from doctor to doctor, and from therapy appointment to therapy appointment. It is really no fun at all.

But, if a long-term employee wants to make a work injury claim, it can probably be done. Any repetitive job has the exposure to start an injury off on the “right” foot. If you do the same job, on the same machine, day after day, then, of course, it makes sense that you could potentially become injured. A lot of the time these claims are for tendonitis. Shoulders get sore, elbows hurt, and it gets harder and harder to work all those hours every week in that same job.

On paper, when adjusters receive a new claim they look at the type of injury, then they look at the person’s date of hire. It can make perfect sense that a five-year employee can get tendonitis from work duties. And, if the medical evidence is there, adjusters lose ammo to fight the claim. These claims are accepted all the time. It is later down the road, when these people do not get any better four months after they reported their injury, that the adjuster really digs in to see what is going on.

Maybe the injury is a combination of work and arthritis. Then the correlation has to be made between what is work related, and what is there due to normal arthritis. Maybe none of this was actually work related, and it is all a worsening of a person’s arthritic condition. The adjuster will find out in the end, but it takes some time to get to this diagnosis and proclamation.

2. They know who to tell:

New employees will run to their supervisor right away and start talking about how something job-related is hurting them. Some of these new employees wait a few months to see if the condition will go away. A lot of times these claims can be based on new job duties, since maybe the worker was unemployed for two years prior to coming to your workplace and they are just out of shape. I do not come across too many employees who have worked somewhere for two weeks, and immediately make a repetitive injury claim. The claim that has the most merit is a traumatic injury claim from a laceration, or a contusion from falling down or being hit by something.

But older employees will play their cards differently. They start off by telling some coworkers about their pain. Then maybe they go to some other supervisors and talk about a job task that is bothering their shoulder. Then finally they make their way to the HR office to actually file the claim. Now, the worker has the backup of all of these other employees supporting their story of ongoing pain over the last few months. This helps them legitimize their story, and it makes it seem less fraudulent. And in some cases they may be right, but that does not mean that their injury is actually caused by work duties. That is for the adjuster to decide.

3. They know what to tell the doctor:

The occupational physician will ask the employee what the job consists of, and what is done on an average day. Workers who have repetitive jobs will sometimes inflate duties to come off as more credible. But physicians will also ask how long they have been there, and how often per day they are doing these tasks. The long-term employee again thinks seniority is on their side and they have more evidence to add to their claim. And, again, that may be true, but it is for the adjuster to decide what is compensable and what is not based on the medical evidence.

One thing seen in medical reports is employees telling doctors they have never had pain like this before in 15 years of work. That is all well and good, if it is true. Chances are it is not. The statements that employees make to their doctors do not hold a lot of weight in the adjuster’s world. Adjusters look at medical evidence, and causal relation. They get job descriptions from the employer, to see if it matches up with the employee statements. And if they do not, that is one red flag raised to show something else is going on with the claim.