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Preventing payment on a fraudulent claim – a win-win

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When suspecting a fraudulent work injury claim, investigating recent chart notes might be the key to preventing an adverse impact to the employer, colleagues, and the Retro Pool.

Recently an injured worker claimed he experienced a back sprain when a 1,500 lb machine tipped over and fell on him. The employer voiced concerns to Brigitte Le Vie, our Claims Analyst, regarding the validity of this machine “falling over” since the bottom-heavy equipment couldn’t have tipped over as claimed without the involvement of an external force.

The RS team’s investigation revealed that the employee’s injuries were inconsistent with the alleged cause, and the one witness was off duty at the time of the alleged incident!

Upon further review of the employee’s health records, Le Vie learned that the worker had sustained injuries from a motorcycle accident the month before the alleged workplace incident and had his first physical therapy treatment the day before the alleged incident occurred.

Suspecting a staged injury to cover treatment costs related to the previous injury, the Department put the Allowance in Abeyance and sent requests to the worker’s attorney for a better description of the alleged incident. The employee and his attorney ignored multiple requests.

If not for the team’s due diligence and a clear presentation of the facts, the Retro Pool would have had to pay for a costly series of treatments through rate increases and possibly a lower retro performance rating. The Department ultimately rejected this claim, saving money for the employer, his colleagues, and the Retro Pool.

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