Identifying Questionable Claims to Prevent Workers’ Compensation Fraud


Questionable claims in Workers’ Compensation represent a very small percentage of claims; however, according to the National Insurance Crime Bureau (NCIB) the number of questionable claims is increasing despite falling claims frequency. Questionable claims are claims that NICB member insurance companies refer to NICB for closer review and investigation based on one or more indicators of possible fraud.

According to a NICB report, the top referral reason is “claimant fraud” which is two and a half times more frequent than any other cause. If fraud is suspected, it’s important to notify the adjuster right away so that a proper dispute for investigative purposes can be filed. The more information provided, the stronger the case.

The second and third top referral reasons are “prior injury/not related to work,”and “malingering.” An injury not related to work is typically one suffered during a recreational or day off activity but reported as a work injury. A malingerer is someone who has suffered a legitimate injury but continues to feign symptoms, thus collecting benefits long after recovery. These are followed by “working while collecting” and “inflated medical billing.”

There are other claims, sometimes referred to as “gray areas” that may not be compensable depending upon the circumstances and the state laws. Some examples are:

• “Coming and Going Rule” – Traveling to and from work or even to and from lunch are generally not compensable, but there are a number of exceptions. These can include travel considered integral to employment, beneficial errands for employer, and injuries suffered by “on-call” employees.

• Off the clock injuries – Workplace injuries that occur when the employee is not working, such as at lunch or on a break, are generally not covered, but there are exceptions.

• Under the influence of drugs or alcohol – Employees who are intoxicated while working are normally not covered for Workers’ Compensation if the intoxicant was a factor in the cause of the accident. The best way to deal with this situation is to have a drug test administered at the time the employee goes in for medical treatment.

• Occupational illnesses – To be compensable, an injury or illness must arise out of or in the course of employment. In some cases, the connection with the job may be questionable. An example is a loss of hearing caused by the job or the natural aging process.

• Recreational activities while on employer’s premises – Compensation for injuries incurred during recreational activities on the employer’s premises are tricky and depend upon the employer’s role in organizing the event, the expectations of employee participation, and the benefit to the employer.

• Horseplay – Shifting attitudes have resulted in compensability for more injuries resulting from horseplay. If it is common at a particular workplace, condoned or even practiced by management, and if the injured employee was clearly an unwilling participant, it has a good chance of being considered compensable. However, some horseplay may be so far removed from normally expected behavior that it cannot be deemed to have arisen in the course of employment.

by Shane Ideus, CIC, CLCS


UNICO Group, Inc.