What’s Allowed in Workers’ Compensation Investigations?

If you suffer a work-related accident and are injured, you can submit a claim for workers’ compensation and you will be provided with a set of benefits, including medical care and a portion of your wages. At least, that’s how it works in theory; real-life workers’ compensation claims can become quite complex, and often require claimants to fight the system for an extended period of time just to receive the benefits to which they are entitled. One major roadblock in the workers’ compensation claims process is the workers’ compensation investigation, which can result in a denial of your claim. If your workers’ compensation claim is under investigation, you should consider contacting a New York workers’ comp lawyer who can advise you on the best path forward. 

When Workers’ Compensation May Launch an Investigation 

When you file a claim with your employer’s workers’ compensation insurance company, the company will want to do its due diligence to ensure that your claim is valid before paying it out. The workers’ compensation program is limited strictly to accidents and injuries that are work-related; hence, establishing whether your accident was truly work-related will be one of the insurance company’s primary goals. While some accidents and injuries are clearly work-related, others fall into gray areas that often require further investigation (e.g., getting into a car accident while running an errand for your boss on your commute to work). 

Some other common situations when workers’ compensation insurance companies may launch investigations include: 

• Large claims: Investigations are more likely when your claim is large, as large claims mean larger losses for insurance companies 
• History of claims: Having a history of filing workers’ compensation claims — even if they were denied — can cause insurance companies to conclude that your accident may be the result of a preexisting condition 
• Suspected fraud: Any aspect of your workers’ compensation claim that suggests fraudulent activity — even if there is a rational explanation for it — is almost guaranteed to trigger an investigation

Scenarios that Indicate Fraud to Insurance Companies 

Fraud in the workers’ compensation system is rare. Frequently, allegations of fraud boil down to honest mistakes when applying for workers’ compensation benefits or simply memory lapses that create the appearance of inconsistency. However, that does not prevent workers’ compensation insurance companies from launching investigations whenever anything seems “off” about a particular claim.

Some common red flags workers’ compensation insurance companies use to justify investigations include: 

• Inconsistent statements about the events of the accident
• The claim was filed after a negative performance review 
• The claim was filed after a request for time off was denied
• There are no witnesses to the accident
• The claimant refuses a certain medical treatment
• The claimant delays reporting the claim 
• The claimant has had recent financial difficulties
• The claimant has a preexisting condition that is similar to the injury
• The claimant engages in a hobby that could cause a similar injury 

None of these scenarios necessarily prove that a claim is fraudulent, but they can nonetheless increase the chances of a workers’ compensation investigation. If any of the above scenarios apply to your claim, please consider speaking to a workman’s comp lawyer. 

What Workers’ Compensation Investigators Look For

When a workers’ compensation insurance company launches an investigation, they typically hire a private investigator who has experience working with these types of cases. The investigation will utilize a number of common investigative techniques, including interviewing the claimant, interviewing witnesses, interviewing the claimant’s medical team, reviewing accident reports and medical records, reviewing company surveillance footage (if available), establishing exactly when and where the accident occurred, inspecting the scene of the accident, reviewing the circumstances surrounding the accident, reviewing the claimant’s employment history, assessing the employer’s safety protocols, and establishing whether the claimant is still working, among many others. 

What Investigators Can and Can’t Do 

Workers’ compensation investigators generally tailor their investigations to the issue that triggered it. For example, if a claimant has a history of making workers’ compensation claims, the investigator likely would focus his or her efforts on digging through the claimant’s medical history to check for preexisting conditions. If the investigator suspected fraud, he or she likely would focus more on reviewing video surveillance and interviewing witnesses than poring over the claimant’s medical history. However, there are limits to what workers’ compensation investigators can do. 

Investigative techniques that are generally allowable include: 

• Following the claimant around (in public places) 
• Taking photographs and videos of the claimant
• Investigating the claimant’s social media posts
• Interviewing the claimant’s friends, family, and coworkers
• Calling the claimant 

Investigate techniques that are not allowed, and therefore illegal, include: 

• Trespassing on private property 
• Concealing the investigator’s identity (such as by posing as a delivery worker) 
• Using fraudulent names to gather information about the claimant 

If your workers’ compensation claim is under investigation and you suspect that your investigator is engaged in illegal surveillance activities, please contact a job accident lawyer. 

What to Do if Your Claim Is under Investigation

The most important advice for claimants who are under investigation is, to be honest. This includes telling the investigator the truth, but also refraining from omitting key information, or “lying by omission.” Dishonesty during the workers’ compensation claims process can seriously compromise your claim, particularly if your claim makes it to the hearing and appeal stages. Workers’ compensation law judges do not look favorably at dishonest claimants. Below are a few more strategies for making the investigation as painless as possible: 

• Respond to the investigator promptly when he or she requests information
• Collect all the documents you can that can help prove that your injury was work-related
• Follow your medical treatment plan 
• Keep lines of communication open with your employer 
• Keep it professional — you don’t have to be friendly with your investigator, but you should at least maintain a professional and courteous demeanor 

Get Help from Turley, Redmond & Rosasco

Being told that your workers’ compensation claim is being investigated can be a nerve-wracking prospect. To minimize the risk of the investigation sinking your claim, please contact a Long Island workers comp lawyer at Turley, Redmond & Rosasco by using our online form or by calling us at 631-582-3700 (Ronkonkoma) or 631-399-0400 (Shirley/Riverhead).