When it Comes to Fraud, the Price is Never Right

Handcuff FraudA North Carolina postal worker claimed a job-related injury prevented her from lifting boxes of mail. Her workers’ comp insurer began paying benefits to her.

Meanwhile, the insurer discovered the woman was a contestant on the “Price is Right.” Her injuries did not prevent her from spinning the giant prize wheel not just once, but twice.

The woman was also spotted lifting furniture, carrying groceries and even ziplining on a cruise. She is set to be sentenced for workers’ comp fraud in September.

Cases such as these are the exception. Most injuries are legitimate, and most claimants genuinely want to recover and return to work. But sometimes, people cheat the system.

Fraud costs the workers’ compensation system approximately $7 billion a year, according to the National Insurance Crime Bureau. Those costs trickle down to everyone in the form of higher premiums.

Fraud is lying for financial gain. Anyone who has a stake in the workers’ comp system can commit fraud, but 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

Insurers have a vested interest in identifying and stopping fraud. In fact, Texas Mutual maintains three teams of in-house fraud investigators.

Still, fighting fraud requires a coordinated effort among all stakeholders. Employers can help if they learn to recognize the warning signs of claimant fraud. If you identify two or more of these red flags in a claim, contact your insurer immediately. You can also report your concerns to the Texas Department of Insurance fraud unit:

  • Tip from a credible source
  • New or disgruntled worker
  • No witness to alleged injury
  • Inconsistent or illogical description of incident
  • Hard to contact injured worker
  • Injured worker acts upset when contacted
  • Suspicious injury on Monday or Friday

 If your insurer opens and investigation, it will need your cooperation. Provide access to witnesses, attend hearings and notify the investigator if you discover new information.

 Together, we can win the fight against fraud one case at a time.

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One Response to When it Comes to Fraud, the Price is Never Right

  1. Love the fraud stories, I always try to tell customers about them in hopes t hat they tell others about them as well. The more people who know how to detect a potential fraud the better.
    Very cool blog post, cheers!

    Julian

    Like

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