A workers’ compensation claim that initially appeared routine ultimately resulted in a felony conviction after an investigation revealed the injured worker had been employed elsewhere while continuing to collect disability benefits.
When suspicious activity raises red flags
The claim involved a construction worker who reported suffering an injury in January 2023 and was subsequently placed off work while awaiting surgery. During that time, the worker received temporary disability benefits based on representations that he was unable to work. Several months later, ICW Group’s Special Investigations Unit (SIU) received information suggesting the claimant was performing construction-related work for another employer despite collecting wage replacement benefits. Surveillance was conducted and documented the individual actively performing job duties at multiple work sites.
Expanding the investigation
The SIU investigation expanded and uncovered that the claimant had been working for the new employer since June 2023 while simultaneously collecting workers’ compensation benefits. When interviewed, the claimant denied working for any employer or receiving an income since his reported injury date in January. Additional surveillance later confirmed continued employment activities.
Medical records obtained during the investigation further revealed concerns that the claimant had been working while reporting that he was unable to do so because of his condition. Following a review of the evidence, the treating physician released the claimant to return to work without restrictions, pending surgery.
By the conclusion of the investigation, more than $53,000 in temporary disability benefits had been paid while evidence showed the claimant was employed elsewhere during a significant portion of the time he was on disability.
A successful outcome
The case was referred to law enforcement, and criminal charges were filed. The claimant ultimately pleaded guilty to one felony count related to workers’ compensation fraud and was ordered to pay full restitution of more than $36,000. The case serves as an important reminder that workers’ compensation benefits are intended to support legitimately injured employees and that misrepresenting work status while receiving benefits can lead to serious criminal and financial consequences.
Fraud prevention takeaway
Workers’ compensation fraud affects employers, insurers, and injured workers alike. Tips from employers, coworkers, and members of the public play an important role in identifying suspicious activity. When concerns are reported early, insurers can investigate, verify the facts, and help ensure benefits are paid appropriately and reserved for those who genuinely need them.
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.
