Not every questionable worker’s compensation claim begins with an obvious red flag. Sometimes, it starts with a simple observation that doesn’t match what has been reported.
In a recent case, a worker reported suffering a serious ankle injury after falling down a staircase at work. The worker sought medical treatment, was diagnosed with a displaced ankle fracture, and ultimately required surgery. Throughout the claim, the worker maintained that the injury occurred at work and denied having problems with the ankle beforehand.
But the employer had information that raised an important question: Was the injury actually sustained at work?
Uncovering the facts
The employer reviewed CCTV footage from the morning of the reported accident. Acting quickly, the claim examiner obtained the employer’s CCTV footage. The video showed the worker arriving at the workplace that morning already walking slowly and with a limp. A coworker also confirmed that the worker appeared injured upon arrival.
That evidence directly contradicted the worker’s account in a later interview where the employee stated that the foot injury occurred on the workplace staircase and specifically reported that he was not injured when he arrived at work.
Because the evidence was identified and preserved quickly, the claim was denied, helping mitigate what could have become a significant workers’ compensation exposure.
From red flag to law enforcement referral
The investigation did not end with the claim decision. ICW Group’s Special Investigations Unit (SIU) referred the matter to law enforcement, and the worker was ultimately charged with two felony counts of insurance fraud.
The case is a powerful example of what can happen when employers, Claims, and SIU work together. The employer’s observations and CCTV provided critical evidence, while the claim examiner’s quick action in obtaining the footage allowed the facts surrounding the reported accident to be evaluated before important evidence could be lost.
Why it matters to employers
This case is an excellent example of why employers can be such an important part of the claims investigation process.
The critical information didn’t come from a complicated investigative technique. It started with the employer recognizing an inconsistency, preserving available CCTV footage, and providing information from someone who had observed the employee arriving at work.
Without those pieces of information, the circumstances surrounding the injury may have been much more difficult to evaluate.
Employers aren’t expected to investigate claims or determine whether fraud has occurred. But they are in a unique position to provide information that the claims professional or SIU may not otherwise have, especially when it involves what happened before or after a reported accident, witness observations, or available video.
The most important thing is to preserve the information you have and communicate concerns to your claims professional as soon as possible. Claims and SIU can take it from there.
This case shows how one observation, supported by timely evidence, can change the direction of an entire claim.
