Workers’ Comp Investigations: The Role of Surveillance

An employee who submitted a workers’ compensation claim has been out on leave, but the adjuster suspects they’ve taken another job while collecting benefits. Maybe the employee is hard to contact during normal business hours. Or a coworker has reported knowledge of possible benefits abuse. Potential red flags like this could not only spur additional workers’ comp investigations but demonstrate the need for surveillance to verify claim details. 

According to the National Insurance Crime Bureau, approximately 10% of all insurance claims may contain some element of fraud. Surveillance conducted by licensed investigators can serve as a powerful tool in uncovering potential misrepresentation or exaggeration. It’s important for adjusters to consult with their investigative partners to determine whether a particular claim is appropriate for surveillance.

The following situations are some examples of when surveillance can play a key role in the workers’ comp investigation process for accurate and fair resolutions.  

A licensed professional investigator can conduct surveillance for an adjuster to verify facts of a workers’ compensation claim. 

High-Value Claims with Questionable Elements 

Several factors determine what constitutes a high-value claim, including severity of the injury, how long the employee is away from work, medical costs, and the impact on the employee’s career.  

 Combined with questionable elements (think suspicious timing, delayed reporting, etc.), this could necessitate further inquiry through social media and background checks or canvassing. 

 Multiple Red Flags Present  

Red flags range from the timing of a claim—filed right after being hired, for instance—to a history of filing claims or of employment at companies with high claim rates. Other questionable activities include reporting more than one claim for the same injury or area. 

 While multiple red flags don’t necessarily mean fraud has occurred, doing your due diligence by having an expert complete surveillance, as well as through social media investigations, canvassing, and background investigations, will help verify the accuracy of the claim. 

 Activities Inconsistent with Claimed Limitations  

Maybe a workers’ comp claim cites a rotator cuff injury, but you’ve heard they’re playing recreational baseball on the weekends. Or a claim denotes a foot injury, but the claimant hasn’t stopped their marathon training. 

Surveillance can include analyzing statements made to adjusters to verify the validity of a workers’ compensation claim. 

These situations could call for statement analysis. In this case, the investigator takes detailed, recorded statements from witnesses and the claimant to refer to as the investigation continues. Digital forensics, such as photo and video analysis, could also verify facts of a claim during workers’ comp investigations. 

 Subjective Injury Claims  

A subjective injury claim focuses more on pain and typically doesn’t include impartial medical findings. 

 For example, a claimant could report soft-tissue injuries, which are harder to diagnose, rather than a broken bone or dislocated joint.  

 The focus on the injury itself leans toward medical canvassing, in which a trained investigator reviews medical records, interviews care providers, and conducts pharmacy checks to verify the claim.  

Soft-tissue injuries are considered subjective injury claims and can be verified by experienced investigators through medical canvassing.

Pursuing Workers’ Comp Investigations 

These scenarios only scratch the surface of techniques for workers’ comp investigations and when to rely on trained, certified professionals to use them. But remember, the methods are not intended to be used in a vacuum. 

 Trained, professional investigators, like those at VRC Investigations, are equipped to navigate not only the nuances of the legal system at the local, state, and federal levels but also have the resources to do so—particularly in these common situations that lead up to the investigation. 

 VRC Investigations, a part of Alpine Intel’s suite of services, is a leading national insurance defense investigation firm, follows proven best practices to deliver timely, actionable reports which empower our clients to make confident claim decisions. A customized surveillance plan is developed for each case in accordance with all applicable laws and regulations to ensure both effectiveness and legal integrity. 

 If you’re unsure of where to begin, submit an assignment with VRC Investigations today. 

Alpine Intel’s content is meant to inform and educate readers using general terms and descriptions. They do not replace expert evaluations that determine facts and details related to each unique claim.