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Summertime and Questionable Workers Compensation Claims

Originally published by Michael B. Stack on https://blog.reduceyourworkerscomp.com

With the arrival of warmer temperatures most employers will start to question an increase in subjective injuries.  This is with good reason since some employees would like to enjoy a little extra R&R without having to take time from their vacation bank of hours.

Most insurance people will tell you that the employer should not make a compensability decision on any claim—this should be left up to the insurance carrier.  But from an underwriting perspective, employers hate to take a hit on their claim counts with potentially questionable injuries.  Sadly, this is part of the business whether you like it or not.  So what can you do to remain proactive on these claims and expose the “questionable” claims without incurring claim dollars and expense?

1.  Utilize your light duty work program

The best deterrent for keeping questionable claims down is to keep workers working.  If the goal of the worker is to get more time off of work, they probably won’t waste their time trying to fool you if they know they will have to work. One of the worst things an employer can do is just send a worker home if they have medical restrictions.  Once word gets around that all a worker has to do is go to a doctor and get some medical restrictions, the floodgates will open.

2.  Be sure that your claims adjusters are aggressive on claims

Every employer wants their carrier to be aggressive on all of their claims.  For the most part the examiners are aggressive, but when you give them information they will work extra hard to expose this injury as being non-compensable.  If the employer fails to communicate to the adjuster that this claim is suspicious, then you lost an opportunity.  However, you can’t cry wolf all of the time.  Every single claim that arrives on your desk is not questionable in nature.  You have to be honest, or else your adjuster will not take you seriously.

3.  Utilize an occupational clinic that is also aggressive in nature

As an employer , you need to work with a clinic for your injured employees medical care.  You need to get out to these clinics and take a tour of the facility, meet the doctors, and know the staff that works there, including the office managers.  This way you know who to alert should something suspicious happen.  If the doctor knows that this injured worker has a checkered past with trying to get some free time off of work, then they know to take a detailed history, and to look for inconsistent findings on exams.

4.  Use surveillance as needed

Another great deterrent to limit questionable claims is to use surveillance.  If workers know that someone may be watching them, they will be less likely to try and pull off a fake injury.  Most workers that want some extra time off of work won’t want to spend it trapped inside their houses wondering if someone is potentially watching every move they make.  Workers will hear about a fellow employee’s claim that was denied due surveillance footage and they will think twice about attempting a fraudulent injury.  This is not to say that you need to do surveillance on every claim, but use it as needed, especially if you know that this employee is a fisherman, a coach, a golfer, and so on.

5.  Enforce your protocol for injury reporting and compliance

Employers that have a protocol for injury reporting and ongoing compliance do so in order to keep up to date on the progress of their injured worker.  This can include bringing in your medical slip after each appointment to the designated employer contact, having regular meetings with the injured worker to go over their restrictions, and enforcing strict attendance for the light duty work program, physical therapy, and doctors appointments.  Each of these factors help to prevent a claim from slipping through the cracks, and violators of the program’s rules need to be disciplined accordingly.  The program and its rules are there for a reason, and any noncompliance needs to be dealt with promptly and effectively.


Questionable claims are going to happen no matter what the season, but once the temperatures start to rise and the sun starts to shine, every worker gets a little case of Spring/Summer fever.  So be aggressive on questionable claims, and do the work to maintain compliance with your injury program and its parameters.  If you stick to your guns and stay proactive, you will limit as much of the exposure as you can.

 Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

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