Workers Compensation Fraud

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 What Is Workers' Compensation?

Workers’ compensation is a type of insurance developed to replace the earnings and cover the medical bills of workers who have been hurt on the job. Typically, in exchange for coverage under the insurance, the worker gives up the freedom to sue for negligence.

The worker can still file suit against their employer or another party if other wrongs happened, such as:

  • Defective products;
  • Exposure to toxic substances;
  • Intentional conduct by your employer;
  • Injury at work; and
  • Failure to carry adequate workers’ compensation insurance.

What Is a Work Injury Lawsuit?

A work injury lawsuit is a legal action involving injuries sustained at the workplace. Workers’ compensation plans often cover on-the-job injuries. These state-mandated programs supply recovery for injured workers under specific work conditions.

Nevertheless, the compensation plan may not cover the particular type of injury involved in some cases. Or, there may be conflicts between the worker and employer concerning liability. In such circumstances, a work injury lawsuit may need to be filed if other compensation methods are futile.

What Should I Do If I am Injured at Work?

Suppose you are injured while at work. It is essential to convey the injury to your employer as soon as possible. There are time limitations to bringing a workplace injury claim, which varies from state to state. Your claim may be rejected if you do not report the injury to your employer within the required time.

Even if you do not think you are injured in the accident, you should still report the incident to your employer because some injuries are not apparent until days after the accident. Inform your employer about the details of the accident and the time it happened. Also, take as many photos of the accident and collect any other evidence and witness statements from those who saw the accident.

What Are Some Examples of Work Injuries?

Some common examples of work injuries include:

Some lines of employment are associated with certain types of injuries more so than others. For example, manufacturing industries often involve injuries from toxic substances. The kind of job is often factored into a work injury lawsuit judgment, especially when courts need to assess the likelihood of an injury happening.

Will Workers’ Compensation Cover Me for Any Work Injury?

Workers’ compensation will cover you for any work-related injuries or conditions. Sometimes, even if the worker caused the accident, they may be able to get workers’ compensation for their injuries or illnesses as long as the worker did not cause the accident under the influence of illicit drugs and alcohol.

It should be mentioned that there is a distinction between a personal injury lawsuit and a worker’s compensation claim. Some individuals think that a workers’ compensation claim is the same as a personal injury claim when this is technically not the case.

What Is Workers’ Compensation Fraud?

Workers’ compensation fraud is when an employee purposefully makes a fraudulent statement or conceals information to obtain workers’ compensation benefits from their employer or stops someone from obtaining benefits to which they might be entitled. It is essential to know that both workers and employers can be held responsible for workers’ compensation fraud.

Employers can be held responsible for worker’ compensation fraud when an employer knowingly falsifies facts about their workers. They may do this for example to get workers’ compensation coverage for a price that is less than what the employer would have to pay if all facts present were known to the insurance company.

What Are Some Examples of Workers’ Compensation Fraud?

Some examples of workers’ compensation examples include the following:

  • Applicant/Claimant fraud: This happens when the injured worker makes incorrect or fakes/exaggerates their injury to obtain workers’ compensation benefits.
  • Adjuster fraud: This happens when an insurance adjuster tampers with evidence to support denying a claim and does not pay the claimant for their injuries. The insurance adjuster usually works for the insurance company.
  • Premium fraud: This happens when the claimant gives fraudulent information to the insurance company to obtain a workers’ comp policy at a discounted rate.
  • Employer fraud: This happens when the employer does not want to pay workers’ compensation and knowingly makes false representations or statements about the claim.

What Are the Elements of Workers’ Compensation Insurance Fraud?

For the prosecutor to be able to convict the defendant of workers’ compensation insurance fraud, the following elements must be satisfied:

  • Defendant knowingly made a false statement;
  • The statement is in connection with a claim or payment made/to be made from an insurance company; and
  • The statement is a key part of the insurance payment or claim.

How Frequently Does Workers’ Compensation Fraud Occur?

While an exact figure is impossible to determine, studies have shown fraud only happens in 1 to 2% of claims. According to the U.S. Bureau of Labor Statistics, more than 3 million nonfatal workplace accidents occur yearly. If 1 to 2% of those are fraudulent, that’s roughly 30,000 to 60,000 instances of fraud.

In a system that costs over $90 billion a year, the dollar amount of that fraud can add up quickly. For instance, in 2011-2012, California had estimated that over 5,000 arrests were made for workers’ compensation fraud, amounting to upwards of $300,000,000 of potential losses.

Who Can Commit Workers’ Compensation Fraud?

While many believe workers only commit this type of fraud, employers and providers can commit workers’ compensation fraud too:

  • Employees: Employees can commit fraud by overstating claims, claiming an injury that never happened, working while a disability claim is being evaluated and not reporting wages, or claiming a non-work-related injury as a work injury.
  • Employers: An employer commits fraud by misclassifying workers, subtracting insurance premiums from their employees’ checks, or by misreporting their coverage.
  • Healthcare Providers: Healthcare providers can also commit workers’ compensation fraud. This type of fraud happens when the medical provider performs unnecessary tests, bills for tests that the provider never performed, or bills multiple times for one treatment.

How Are Work Injury Lawsuits Resolved?

Work injury lawsuits are often resolved through a monetary damages award. This will help the injured party recover losses such as medical costs and lost profits. Documentation is required to support the damages award claim, and an expert witness may be called in to confirm the extent of the injuries and losses.

In some instances, a work injury lawsuit may discover problematic elements of that particular work environment. After the lawsuit, a more extensive scale investigation may be conducted. Alternatively, the court may order the employer to improve their company policies to implement safety standards.

Should I Seek Legal Advice?

Workers’ compensation is designed to facilitate the rapid treatment of injuries that happen on the job. Unfortunately, fraud can complicate this system and hurt those who have already unnecessarily suffered. If you sense you have been subject to workers’ compensation fraud, consulting with a local workers’ compensation attorney can help ensure your rights are guarded.

If you fear an employee is abusing your workers’ compensation insurance, an experienced attorney can help you manage the situation. Use LegalMatch to start resolving your workers’ compensation issues today.

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