Investigating a Workers’ Compensation Claim

There are many important components of a workers’ compensation case.  Proper paperwork, obtaining medical treatment, and sorting out reasonable and necessary accommodations are just a few examples.  Investigating a workers’ compensation claim is also an important component.

When an employee sustains a work-related injury, the first step is, of course, to make sure that employee receives the necessary, immediate medical treatment.  Once it is confirmed that the situation is no longer an emergency, the employer can then turn to the administrative side.  An employer is required to provide the workers’ compensation claim form to the employee within one working day of being notified of the injury.  The employer should also move forward to an investigation.

Investigating a workers’ compensation claim does not mean that you suspect the injured employee of lying or taking other fraudulent action.  Moreover, regulation 10109(a) provides that a claims administrator “must conduct a reasonable and timely investigation upon receiving notice or knowledge of an injury or claim for a workers’ compensation benefit.”  This means that an investigation is not just advisable, but required.  If the investigation is not completed within the time limit, then section 5401 provides that the injury shall be presumed to be compensable under workers’ compensation.

A proper investigation often means collecting evidence from more than one source.  If there is video surveillance covering the area where the employee sustained an injury, that video surveillance footage often provides crucial and best information about how the injury occurred.  Eye witness accounts also may provide important information.  Eye witness accounts should be gathered immediately, as the longer you wait to record that information, the less likely it is that the witness statements will be completely accurate.  An investigation can also include talking with other employees or supervisors who work in the same area, even if they did not witness the event.  They may have information about how work is usually performed, how equipment functions, and the likelihood that the injury occurred in the manner explained by the injured employee.

An investigation can and should also include a review of social media.  Although the vast majority of workers’ compensation claims are valid, a small percentage are fraudulent.  Following social media can provide claims administrators or employers with clues that the employee is not as injured as claimed.

We have extensive experience in workers’ compensation cases ranging from minor injuries to death of an employee. Contact us today for a consultation to talk about your business.

Fraud and People v. Snow

The State of California has taken many steps in recent years and legislative sessions to lessen the amount of fraud perpetrated in the workers’ compensation system. During the fiscal year of 2015-2016, the California Fraud Division reported over 5,300 cases of suspected workers’ compensation fraud and made 249 arrests. Although the vast majority of employees who sustain a work-related injury have valid claims, there are some unfortunate cases when the employee is defrauding his or her employee. When this happens, employees may face criminal prosecution under a variety of legal theories.

In People v. Snow, the employee faced a number of repercussions for her fraudulent behavior. In that case, the defendant worked at Trader Joe’s stocking shelves, gathering shopping carts from the parking lot, customer service, and other similar tasks. The defendant made a claim for workers’ compensation claiming that her wrist hurt and she had sustained injury from repetitive action required in performing her job duties. The defendant’s claim was approved for three months of disability benefits. After the defendant returned to work, she claimed on her first day back to have injured her back while bringing three shopping carts in from the parking lot. Although she was later cleared to return to work, she did not do so, and instead sought treatment from a new doctor, claiming she had pain while doing household tasks such as laundry, dishes, and driving – claims she repeated during a deposition. The supervisory claims adjustor determined the second claim required further investigation and hired a private investigator. The investigator observed her at the beach, lifting a paddleboard from the roof of her SUV and carrying it and the paddle approximately 150 feet to the beach. After paddleboarding for approximately 45 minutes, the defendant returned to shore and carried the paddleboard and paddle back to the SUV and strapped the on the roof herself. Nevertheless, the defendant persisted in telling her doctors she could not lift things over her shoulder or stand for prolonged periods of time, which she repeated during depositions. Ultimately, the defendant was charged with perjury after the video of the defendant at the beach completely undermined her claim of disability. Thereafter, the defendant was charged not only with insurance fraud but also with perjury based on statements made at depositions concerning her second workers’ compensation claim. She was ultimately convicted of two counts of perjury as well as three counts of making false or fraudulent statements to obtain workers’ compensation benefits. Although the defendant then appealed her conviction claiming that this violated her right against double jeopardy as the convictions were based on the same incidents, the court disagreed and affirmed her convictions.

Workers’ compensation fraud is a serious problem and you should take all steps to protect your business. Contact me today at (714) 516-8188 if you wish to discuss fraud and protect your  business.

Making Sure You Properly Investigate an Injury

Making Sure You Properly Investigate an Injury

All workers’ compensation claims have one thing in common – they all start with an alleged work-related injury.  A savvy and conscientious employer will have procedures in place, ready to go for when an employee reports  an injury on the job.  These procedures include obtaining medical care, providing necessary forms and paperwork to the employee, and investigating the injury properly.  Failure to conduct a proper and thorough investigation of a work-related injury sustained by an employee could lead to much bigger problems down the road.

It is first essential to obtain a completely clear account of the accident directly from the injured employee.  This account should be in writing, and should provide as many details as the employee can recall.  Every step should be taken to get this written account as soon as possible following the injury.  By providing a description of the event and the injury early on, it will be much more difficult for an employee to fraudulently expand the injury at a later date.  For example, if an employee injures her hand during an accident, if she has already provided this written account, it will be much more difficult for her to later include her foot as part of a work-related injury.  Getting a clear account of the accident can also provide important feedback to an employer about how to prevent similar injuries to other employees in the future.

Another critical step is to obtain witness statements.  Like the statement from the employee, the witness statement should be in writing and gathered as soon as possible following the incident.  Witness statements will assist in rooting out inconsistencies between an employee’s claimed injury and what actually happened.  Having a supervisor review the witness and employee statements is also an important step.  The supervisor can provide important insight as to whether the claimed injury is an injury that is realistic or if it shows red flags of fraud.

If there are red flags, an employer may want to consider hiring a private investigator to look into the employee’s behavior outside of work.  An investigator can give the employer insight as to whether the employee is engaging in activities that are inconsistent with a claimed injury.

Although the vast majority of workers’ compensation claims are legitimate, it is very important to investigate each injury with as much detail as possible.  Contact us today at (714) 516-8188  to talk about your case and what investigative steps should be taken for your business.

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