Investigate Workplace Injury Claim, including Suspected Fraud

 We investigate a workplace injury claim, both due diligence investigation, and suspected claim fraud, phone 1300 966 103, free quotes, email [email protected], or use our 24/7 online form Contact Us. Workplace accidents will happen, as humans make mistakes, that is why we carry insurance.

The seriousness of the risk associated with a workplace incident is generally calculated by probability of it happening multiplied by the consequence of it happening, multiplied by how often the task is performed (the exposure). Workcover investigators and safety risk managers use this risk assessment method.

When an accident does happen there are a number of steps everyone must perform. The basic ones are to render any first aid required, record the details of what occurred and to report it. Things can go wrong right from the start, with people hiding injuries, and not reporting them. The company is then deprived of the ability to investigate the incident, established what really happened, and to look at how to prevent it happening again.

The next area where problems occur is in failing to effectively investigate and record the circumstances surrounding the accident, sometimes this failure is not discovered until years later, when a civil court case commences. This is where the services of a private investigator start coming in, close to the incident, to ensure evidence is recorded. After any accident where a person is injured, and must take time off work, there is an insurance claim.

It may be to a government entity such as Workcover or for the self insured the cost may be attributed to a unit of the employer, or a private Workers Compensation insurance scheme. Employers must be aware that Workers Compensation insurance claims have been, and will be, subject to claims fraud; that is not to say all claims are fraudulent, because they aren't.

The incident is recorded by the insurer, and any costs associated used as part of the history when setting the future insurance premium cost. Generally for years one through three it is the cost of any time off work. Year five the cost of any court action starts cutting in, usually the biggest kick up in the cost.

  For the self insured they may have to carry the cost of ongoing claims and then a payout. If you suspect a fraudulent claim, you need to act. Private investigators are used to establish and record the surrounding circumstances to an incident, they are also used to investigate claimed restrictions. To be effective they should be bought in early. Some of the things to look for, when assessing the truth of a claim include the number of witnesses, and especially for a Monday morning claim with no witnesses, what the claimant was up to on the weekend!

You can also see trends where there is a successful claim against a company, and then other incidents and accidents start happening. This may especially be true if the contract is coming to an end, or people are about to be laid off. There appear to be some groups who get together to exchange information on what doctor to go to, and what to say. When you see a person on the South side traveling all the way across the city to see a doctor on the North side, without any other reason, this is a cause for suspicion; especially where there was concern about the original claim. You may hear that a worker who is off, totally incapacitated, who has just bought a jet ski, or is skitting on Facebook about his five day reef fishing trip.

  This is the second area where a private investigator is employed, surveillance.  A private investigator is used to confirm or deny a claimed restriction; they are the independent observer.  Surveillance by a private investigator was once a standard method used by Workcover, but now the private investigators are quite often employed by the insured party directly.
The amount to spend on surveillance is dictated by three things. it is legal, and should be the least intrusive method of investigating, as there is usually no intention of the surveillance operative and the subject meeting.

The first consideration is the amount of exposure. If you have a worker in their twenties who is claiming totally and permanent disability, and who claims to need a carer for the rest of their life it is definitely verifying their restriction, more than once, over a period of time; we have done such observations for months at a time with some surprising results. Who knew a totally incapacitated person could launch a tinny and go fishing all day by themselves! A workplace injury claim, a workplace injury claim fraud, Workers Compensation fraud, is a risk to the business, the employer.

The second is what information is coming to light from social media and other workers about the claimant. If you are being told its a scam and that he is out surfing every morning this may be an indication that it is a scam! This happens.
The third is the indicators of claim fraud. Is the injured worker doctor shopping, failing to participate in return to work activities, actively avoiding contact, getting worse not better, failing to attend arranged meetings, or observed walking fine in town, but limping when they come to the office? If you suspect things aren't right, contact us for a quote.

Often, if a claim is accepted, and the original injury occurred in the workplace, the discussion is about the level of civil compensation that the claimant is entitled to, this is where a comparison of the displayed restrictions with the claimed restrictions becomes important, this negotiation about compensation, depending on the amount of evidence the employer holds, may go on until the morning of court (and occasionally to court).

DO NOT discuss any potential use of private investigators with staff.  DO NOT discuss the use of private investigators with the Workcover claim manager.  The 'client' of Workcover is the injured worker, no matter who pays the premium. Some rehab managers have been known to tell the injured worker that you intend to put them under surveillance! Some staff have been known to discuss your employment of a private investigator with mates and coworkers; it doesn't take long to get to the ear of a fraudulent claimant.

For more about Workcover investigations or Workers Compensation fraud, or to investigate a workplace injury claim, call us for a free quote; we aren't cheap but the cost is nothing compared to the cost of Workcover fraud. You must establish your Workers Compensation fraud suspicion to the civil reasonably suspect, as a minnimum, before the insurance will act, nice a claim is accepted.