Benefit Claims – Warning Signs

September 11, 2018

Benefit claim fraud and abuse can deliver significant challenges to organizations. Enclosed you will find some helpful information to assist you in identifying questionable claims as well as best practices.

Problematic claims tend to revolve around the following:

  • Fake injuries
  • Exaggerated injuries
  • Old reoccurring injuries
  • Non-work-related injuries – claimed as a work injury

Why do individuals abuse benefit claims?

  • Additional time off
  • Do not like the current job they have
  • Individuals wants modified or light duty work
  • They have another job or interest

Warning Signs

  • The incident was not immediately reported, and there was no explanation regarding the delay
  • No witness to the incident
  • Employee did not seek medical attention
  • Employee refused treatment
  • Employee’s story is inconsistent
  • Diagnosed injury does not align with the incident
  • History of claims
  • Medical notes are vague and do not provide restrictions/limitations
  • Employee is hard to reach
  • Return to work meetings, and appointments are often missed
  • Restrictions seem excessive – based on the nature of the injury
  • Sudden change in medical providers
  • Employer is seeing similar claims from the same doctor
  • Employee is rumoured to have a side job or other interests outside of work
  • Accident occurs before a layoff, strike, long weekend or holiday
  • Accident occurs before termination or discipline
  • Employee can perform tasks outside their restrictions when not at the workplace
  • Employee engages third-party representation immediately

When a claim presents the above warning signs, the following should be considered:

  • Conduct a detailed internal investigation into the incident that includes the employee’s social media and online activity (before the employee ‘goes dark’)
    • Most people post all aspects of their lives online (Cost range $75-$375 per file)
  • Challenge validity of claim quickly – claims are often rubber stamped because the employer does not contest
  • Get restrictions immediately
  • Offer modified duties as soon as possible to get them back to work
  • Be prepared to manage the claim aggressively – the employee is banking you will give up
  • Work with other stakeholders
  • Engage surveillance when the employee is not participating in any return to work programs
    • ($1200 to $1500 per day)

Steps to consider after social media or surveillance investigation:

  • Meet with the employee
  • Ask them questions you know the answer to:
    • Can you drive?
    • Are you able to do yard work?
    • Are you still unable to stand for longer than 10 minutes?
  • If the employee is deceitful, it lends credibility to your case
  • You may elect to re-offer modified duties:
    • That match the activity observed
    • Goal is to have the employee provide written documentation that they cannot perform these duties
  • You may wish to engage a second round of surveillance
    • The feedback received did not align with observations
    • Found employee acting outside their restrictions
    • Show the employee the evidence
    • This often garners an immediate return to work

The test of reasonability should always be considered. During any proceedings, the employee will attempt to paint the employer in a negative light. You need to be able to demonstrate all the steps taken to have the employee return to the workplace. Ensure you do not appear heavy-handed in your approach.

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