Workers' Compensation Fraud

Workers’ compensation provides benefits for workers who are injured on the job. After suffering a workplace injury, your benefits may suddenly be cut off, leaving you without an income. To make matters worse, injured employees could get notice of an investigation for insurance fraud, with possible criminal penalties.

Workers’ comp fraud is a type of insurance fraud that could result in felony criminal charges, jail time, and expensive fines. Some injured workers are accused of insurance fraud even after suffering severe job injuries. If you have been charged with lying about workplace injuries, talk to a criminal defense lawyer about your rights and defense strategies.

What Is Workers’ Compensation Fraud?

While requirements vary from jurisdiction to jurisdiction, most employers must carry workers’ compensation insurance. This is to provide benefits for workers injured while in the course of their job. Workers’ comp is a no-fault system where the worker does not have to show the employer was negligent in causing the injury. As a trade-off, the worker only gets limited benefits, including:

• Medical care
• Disability benefits
• Income benefits

Fraud involves knowingly making false representations to obtain benefits. This could include making false claims about the injury or helping someone submit false claims. Some ways that someone could commit workers’ compensation fraud include:

• Claiming a workplace accident for an injury that happened somewhere else
• Claiming the injury was more severe than it is
• Working another job while claiming benefits
• Intentionally causing an injury to claim benefits

An injured employee may be able to claim benefits for a while and later be accused of fraud. If the workers are found to be committing fraud, they may be responsible for repaying all their benefits, in addition to other financial penalties.

Workers’ Comp Insurance Investigations

How do the police and prosecutors find out about workers’ compensation fraud? Workers’ compensation Insurance companies and employers often report suspected fraud or false claims. Workers’ compensation insurance providers have a financial interest in paying out as few claims as possible. Like other insurance companies, they look for potential red flags indicating workers comp fraud.

The insurance companies may use investigators to check up on injured workers to find any reason to deny their claim, including:

• Photographing claimants who are participating in sports or carrying groceries
• Videotaping workers who are participating in sports or gardening
• Talking to other employees or neighbors
• Looking through Facebook and social media to find conflicting information

While the size and duration of workers’ compensation benefits vary from state to state and often depend on the scope of the injury, individuals found guilty of fraudulent activity will likely have to pay the benefits they have received back.

Who Is Charged With Criminal Workers’ Comp Fraud?

It is not only workers who can be accused of fraudulent workers’ comp claims. Anyone involved in the claim process could be accused of fraud, including:

• Co-workers who cover for fraudulent claims
• Employers who fraudulently deny a valid claim
• Doctors who make false permanent disability claims
• Chiropractors who bill for treatment never provided
• Health care providers or medical providers who double bill for treatment

Workers’ compensation coverage is designed and in place to provide for injured workers to recover medical expenses for a work-related injury. The Department of Labor treats misrepresentation or outright fraud – provider fraud, employer fraud, or employee fraud – seriously. The entire workers’ compensation system relies on honesty.

Penalties for Workers’ Compensation Insurance Fraud

States take insurance fraud very seriously. Workers’ compensation fraud can be charged as a felony, with penalties including prison time, fines, and restitution. The penalties may be more serious when fraud involves a lot of money, multiple people, or when fraud was committed as part of an organized criminal enterprise.

Consequences of Felony Fraud Convictions

In addition to the penalties that come with a felony criminal charge, there are long-term consequences of a felony conviction. Being convicted of a felony can limit your future job opportunities. A felony record can make it harder to get benefits or housing. A felony can also prevent you from owning a firearm.

Legal Defense for Workers Comp Fraud

If your employer or the insurance company accuses you of fraud, ask a criminal defense lawyer for advice. Some employers use accusations of fraud as a way to stop you from fighting for your benefits. Workers’ compensation fraud attorneys can help you through the process so you continue to receive your coverage and payments. There are several legal defenses for workers’ comp fraud allegations.

For example, your doctor could have suggested light exercise as a way to improve your back pain caused by a workplace injury. The insurance company may take pictures of playing tennis as a way to show your injury was not serious. Severe and debilitating workplace injuries can be improved by following your doctor’s advice. You should not be penalized for trying to improve your injuries.

Your employer or the insurance company may try to report you for insurance fraud as a way to deny your benefits. If you were accused of workers’ compensation fraud after an on-the-job injury, talk to your experienced criminal defense attorney to help you keep your benefits and avoid a criminal record.