ICW Group’s Special Investigations Unit was recently engaged in a questionable claim, and the policyholder’s support proved crucial to its adjudication. This example demonstrates how a cohesive partnership between the policyholder, the Claims Examiner, and SIU was able to affect a positive result.
The claim involved a 38-year-old courier who had a near slip on the step of a van while exiting the vehicle, initially complaining of low back and knee pain. He missed two days from work, treated for one week, then returned to full duties without issue. Three months later, the injured worker stated he reaggravated his back injury and wanted to resume treatment.
The doctor placed the injured worker on modified duties which were accommodated by the employer, though the employee only showed up for work two out of ten days. Surveillance was requested as a result of the three-month gap in treatment, as well as a tip from the employer. The Injured Worker was observed playing in a baseball league on the weekends. Video showed the injured worker carrying a canopy, pulling a wagon, and playing in a full baseball game for hours – including throwing a ball, swinging a bat, running bases, and squatting to field ground balls.
The Claims Examiner spoke to the injured worker’s wife three days after the video was taken, and she alleged the injured worker was in too much pain to work, that she has to help him get into and out of the car and bed daily, and that the employer has him working outside of his modified duties. Two days after he was documented playing in another baseball game, the injured worker indicated that while he was able to touch his toes, he felt significant pain doing so, alleging that his back pain is constant and severe.
Further investigation from our SIU department revealed the injured worker was involved in a personal auto accident three weeks after the initial injury date. Thorough investigative work revealed the injured worker alleged a back injury in that event and retained an attorney seeking compensation for concurrent injuries. This fact was not disclosed to ICW Group or the employer.
This case was referred to the National Insurance Crime Bureau, California Department of Insurance, and local authorities and is pending further review.
This case demonstrates that even small details from coworkers and managers can be the lynchpin of a successful investigation into suspected insurance fraud. These details can assist in providing the pertinent information needed to make surveillance successful, thus providing the evidence to detect, deter, and defeat insurance fraud.
For more tips on how to defend yourself and your business from fraud, visit our policyholder website.
