A Workers' Compensation Fraud Win
We’ve all heard this story multiple times: An employee alleges a work-related injury, and either the facts don’t seem to add up, or the continued complaints and treatment seem excessive. The employee is unmotivated to return to work, and the cost of the claim is escalating. (Dramatic pause.) So, what now? For a lot of claims, this is a good time to attempt an Independent Medical Examination (IME), conduct a social media investigation or utilize surveillance. These solutions work, as Assurance experienced firsthand. Here's how:
A construction worker alleged he sustained a work-related injury to his shoulder and back. The initial description of loss, while not egregiously different, did contain some inconsistencies between the initial statement given to his employer and what was provided to the adjuster in his recorded statement. The employee had some positive findings in his diagnostic tests, however, these didn’t seem to match the mechanism of injury. Despite these facts, the adjuster wasn’t in a position to successfully suspend benefits, as under Illinois Workers’ Compensation Statues, there was an incident as well as symptoms and a diagnosis that could have been caused or aggravated by this incident.
Assurance and the client didn’t accept this answer and partnered with the carrier to have surveillance obtained. The surveillance, taken over multiple days, demonstrated this very individual consistently working. An IME was obtained to confirm the employee’s actions on video demonstrated an ability to work full duty. It’s safe to say the next steps taken were critical. A decision was made to present this case to the Illinois Workers' Compensation Fraud Unit. The facts were reviewed by their staff, and they agreed to take this case to the attorney general.
The case was successfully prosecuted with an initial sentence of six months, along with an order for restitution. While an appeal by the former employee resulted in a reduced sentence to only the restitution order, the felony conviction still stands.
With the felony conviction secured, the next step was trying the workers’ compensation claims. So think about it – the burden of proof for a criminal court is much greater than the burden of proof required at the Illinois Industrial Commission. Obviously, there was still a requirement to try this at the Industrial Commission, and after a number of continuances and a few months of waiting for the decision, a zero award was received.
On a good day, the exposure on this claim was an annual wage loss of $28,000 for 18 years, or $504,000. Based on the successful fraud conviction, the medical and indemnity spend to date was $5,957 (which is taking into account the restitution received to date). The diligence of the client in the investigation, and our partnership in ensuring the carrier was only covering what was owed, resulted in just shy of $500,000 in savings for our client and justice served.
- Using Social Media in Claims Investigations
- Workers' Compensation E-Book
- Workers' Compensation Videos
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