The Umbrella and the Circus Tent

By Eileen Cook, Special Investigations Supervisor

By Eileen Cook, Special Investigations Supervisor

I typically avoid resorting to obscure analogies to make a point. I am, however, going to make a rare exception. I think it will paint a vivid picture for anyone interested in combatting the trickle-down effects of workers’ compensation fraud.

I can’t tell you how many times an employer has contacted my team with fraud tips along these lines: “He’s walking most days at the mall; he’s not hurt.”  “He was sitting on his front porch laughing with neighbors; he’s not hurt.”

It seems the number of claimant activities we chalk up as fraud would fit under a circus tent. In reality, the number of activities we can prove – and prove is the key word – as fraudulent would fit under something more the size of an umbrella. They are, in no particular order:

  • an injury that did not happen at all
  • an injury that occurred, but not at work
  • a continuing claim for disability when there is no disability
  • working at another job while receiving benefits for not being able to work

The good news is that I’ve been in this industry a long time, and I assure you most injured workers simply want to get well and return to the job. They’re not out to cheat the system or their employers. Their injuries cause them not only physical pain but also financial stress. Remember, workers’ comp benefits replace only a portion of injured workers’ lost wages.

So if all those claimants under the circus tent aren’t committing fraud, what are they doing? If they’re taking longer than expected to recover, they might be engaging in an activity investigators call malingering.

Think of malingering as stretching the limits of worker’s comp benefits. At the shallow end, the injured worker takes an extra day or two off work. At the deep end, the injured worker is off work so long that he develops a disability mindset.

Fortunately, there is a cure for malingering. Several cures, actually:

  • Commit to a return-to-work program. This is an employer’s best defense against malingering. The program documents how the employer, the injured worker and the doctor will cooperate to get the injured worker well and back to productive employment as soon as medically reasonable.
  • Communicate with the injured worker. Employers should stay in regular contact with injured workers. This will let the worker know the employer cares about his or her well-being. It may also raise a red flag for possible fraud. If an injured worker is difficult to contact while off work or acts annoyed when contacted, he or she may be committing fraud.
  • Talk to the adjuster. Employers should immediately contact the      adjuster handling the claim if they suspect an injured worker is malingering. If the injured worker needs extra help getting back to work, a case manager may intervene.

Winning the fight against workers’ compensation fraud requires a collaborative effort among insurance companies, regulatory agencies and employers. The better we understand what fraud is, and just as importantly, what fraud is not, the more equipped we are to identify and stop those who are truly cheating the system.

About the author
Eileen Cook has more than 40 years’ experience in law enforcement and fraud investigations. She spent 12 years as an investigator with the Brazoria and Midland County Sheriff’s Departments. After leaving law enforcement, Cook served as a training specialist at the Texas State University Institute of Criminal Justice Studies, where she trained police and probation officers for 10 years. Eileen has been helping Texas Mutual fight fraud and its cascading effects on policyholders since 1995. Cook earned a degree criminal justice from the University of Houston at Clear Lake City.

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