Preventing Workers’ Comp Fraud

The majority of workers’ comp claims filed in Texas and other states stem from real instances of on-the-job injuries. Unfortunately, the people who cheat the system drive up costs for employers, consumers and insurers.

As a corporate executive once noted, if workers’ comp fraud were a legitimate business in the United States, it would rank among the Fortune 500 companies. Indeed, according to the National Insurance Crime Bureau, workers’ comp fraud totals $7.2 billion a year. The Texas Department of Insurance notes that insurance fraud is the second most profitable crime after drug trafficking.

Fraud is

Fraud is lying for financial gain. Claimant fraud is the most common type of fraud. Claimant fraud happens when workers:

• Fake or exaggerate injuries
• Collect benefits for injuries that were not work-related
• Double-dip, or continue to collect benefits after returning to work
• Engage in activities that are inconsistent with their injuries

Fraud is not

Delayed recovery. Some injured workers take longer than expected to recover and return to work. This is not fraud. Injured workers do not have to return to the job until their treating doctor releases them.

Recreational activities. Injured workers can participate in recreational activities that are consistent with their medical restrictions.

Suspicion without evidence. To prove fraud, a carrier must have evidence that the injured worker knowingly collected benefits he or she was not entitled to. Evidence includes medical records, witness testimony, business records and surveillance video.