Inside Retail Services News

RS claims adjuster investigates and proves a fraudulent injury claim

Senior Claims Analyst Michele Whinery reports positive results from a recent injury claim that did not stand the test of further examination.

A claimant filed for alleged knee injuries suffered on the job. Retail Services challenged the claim due to inconsistencies in the file and based on a company video that did not show the claimant limping during the mentioned work task, but afterward as he was about to meet and talk with a co-worker.

Whinery challenged the claim allowance and newly contended conditions by obtaining an independent medical examination. Retail Services has the opportunity to challenge the claim allowance further, but the case resulted in an overpayment of nearly $14,000 to the claimant, along with the denial of three knee conditions found to be unrelated.

This allowed Retail Services to obtain a claim closure without any permanent disability order and the unlikelihood of reopening. Because such claims work by Retail Services’ adjusters reduces wasteful payments, it helps to hold down insurance premiums charged to both employers and employees. This is one of the main benefits of membership in Retail Services’ Retro program that awards partial premium refunds to companies that maintain a safe work environment.

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