Workers’ Comp Red Flag Checklist

While most Workers’ Comp claims are legitimate, fraudulent claims occur and drive up costs unnecessarily. Red flags are indicators that the claim requires further investigation to assess legitimacy. The applicability of one or even several of these flags does not necessarily mean the claim is fraudulent, but it warrants further examination:

  1. Unexplainable delay in reporting
  2. No witnesses to the alleged injury-producing incident
  3. Insufficient detail was provided surrounding the injury-producing incident
  4. Alleged injury seems inconceivable considering the work which the claimant performs
  5. Injury is not visible (e.g., soft tissue injury)
  6. Degree of injury is not likely to result from alleged injury-producing incident
  7. Allegations or rumors of fraud and/or the claimant has been observed working elsewhere
  8. Incident was reported on a Monday morning (or after one or more days off work)
  9. Claimant has recently purchased disability insurance
  10. Claimant is a new employee
  11. Claimant has no health insurance coverage
  12. Claimant has used all available sick days and vacation days
  13. Claimant is known to have personal financial problems
  14. Claimant is physically active outside
  15. Claimant has submitted Worker’s Compensation claims in the past
  16. Inconsistencies revealed from the claimant’s initial description of the injury-producing incident
  17. Claimant is unusually familiar with the Workers’ Compensation system
  18. Claimant is uncooperative and/or objects to administrative controls intended to address Workers’ Compensation fraud
  19. Claimant does not provide a street address for a residence
  20. Employer is frequently unable to contact the claimant while off work due to an alleged injury
  21. Claimant obtained legal representation soon after the alleged incident and/or has obtained legal counsel with a questionable reputation
  22. Claimant has indemnity checks mailed to his/her residence
  23. Subsequent medical evaluations apparently contradict the initial evaluation
  24. Employee has missed scheduled physician visits or rehabilitation appointments
  25. Treatment being provided seems more extensive than the injury warrants
  26. Claimant has changed medical providers more than once after the initial treatment
  27. Claimant has been referred to a medical provider close in proximity to the referring medical provider

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The Seltzer Group with locations in Schuylkill Haven, Orwigsburg, and Pottsville, Pennsylvania, serves businesses and individuals locally, regionally, and on the national level. The Seltzer Group is a proud member of the Keystone Insurers Group.

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Workers’ Comp Red Flag Checklist was last modified: August 26th, 2014 by Sarah McGorry