WORKERS’ COMPENSATION CLAIMS

According to the CAIF (Coalition Against Insurance Fraud), fraud steals $80 billion a year across all lines of insurance. Unfortunately, workers’ compensation fraud takes a noteworthy share of that responsibility. As such, WC fraud & exaggeration cannot be taken lightly. Investigating a potential workers’ compensation fraud/exaggeration case requires a different path of understanding. There are many moving parts that need to be considered when conducting an investigation. In my business, the “one size fits all” mentality simply does not work. To be successful you need to understand the BIG PICTURE from the respondent perspective and the insurer perspective.

RESPONDENTS must contend with the employee-employer relationship which involves concerns such as return-to-work issues, proper notice, terminations of employees who allege workers’ compensation claims, first reports, ADA, FMLA, COBRA, OSHA, HIPAA and myriad other problems.

Conversely, INSURERS and TPA’s must contend with concerns such as statutes, causation, exposure, claims handling, administration, compensation payments, time constraints, cost containment, subrogation, third-party litigation, jurisdiction, etc.

From an INVESTIGATIVE perspective, we must focus on concerns such as pre-existing conditions, non-work related injuries, red flags, credibility, unique WC nuances for each state, delayed reporting, investigative budget, maximum impact for low-exposure cases, evidence procurement, trial testimony, etc.

mikecaldarazzo.com understands and contributes to both verticals (workers compensation & disability insurers). This site was designed to address both of our concerns…, as we are all members of the investigative/claims communities.