A workers’ compensation claim that began as a reported workplace injury ultimately revealed a much different story: one that highlights the real impact of fraud on the system.
A worker initially reported an injury sustained while performing job duties for an ICW Group policyholder and was approved for Temporary Total Disability (TTD) benefits. As part of the claims process, she participated in both a deposition and a Qualified Medical Evaluation. During each of these, she clearly stated that she was not working and was not receiving any additional disability-related income.
However, further investigation told a different story.
Over the course of several months, records showed the claimant had been receiving state disability benefits totaling more than $12,000. At the same time, surveillance uncovered that she was actively working at a childcare facility; work she had reportedly been performing for approximately two years, overlapping with the period she was collecting disability benefits.
Despite multiple opportunities to clarify her employment status, she continued to deny working, even stating she was still awaiting medical clearance to return to work.
Video evidence and on-site observations ultimately confirmed ongoing employment during the period of claimed disability.
As a result, it was determined that the worker had been overpaid for approximately $27,000 in indemnity benefits. When factoring in the full cost of the claim, including investigation and administrative expenses, the total financial impact exceeded $53,000.
ICW Group’s Special Investigations Unit (SIU) referred the case to law enforcement and resulted in felony insurance fraud charges.
Why This Matters
Cases like this reinforce the importance of thorough investigation and vigilance. Fraud not only drives up costs for employers and insurers, but it also undermines the integrity of the system designed to support legitimately injured workers.
Customers are encouraged to visit the Policyholder Perks section of our website for more information on how ICW Group can partner with you to detect, deter, and defeat fraud.
