Top Monongahela, PA Workers' Compensation Fraud Lawyers Near You

What Is Workers’ Compensation?

Workers’ compensation provides benefits for workers who are injured on the job or suffer a work-related illness. Most employers are required to provide workers’ comp insurance for employees. When an employee is injured in the workplace, a workers’ comp claim provides medical coverage and partial wage replacement while the employee is unable to work.

The workers’ compensation process is generally a no-fault system. The employee is supposed to be covered for any work-related accident or occupational diseases. The worker does not have to show the employer was negligent. In return, the employer is protected from most personal injury lawsuits related to the accident and the compensation claims are limited to wage benefits, medical care, and disability benefits.

If employers or workers comp insurance carriers suspect the employee is committing fraud, they may investigate the claim to deny coverage or report the employee for fraud. If criminal fraud is suspected, law enforcement agencies may work with the insurance provider and employer to investigate the worker and could prosecute the worker for criminal charges.

What Qualifies as Workers’ Comp Fraud in Pennsylvania?

Workers’ comp fraud involves fraud or misrepresentation in a workplace injury claim. Fraud may involve the worker trying to claim benefits for a non-covered injury or claim benefits when they are still able to work. Some examples of workers’ comp fraud include:

• Claiming a non-workplace injury happened on the job
• Claiming to be disabled when the worker can still perform their job functions
• Intentionally causing an accident or injury to get benefits
• Working another job under the table while receiving benefits
• Advising other workers on how to fraudulently claim workers’ comp benefits
• Filing multiple claims for the same injury

Fraud in workers’ comp claims can also involve health care providers. Doctors, medical service providers, and chiropractors may work together to defraud the workers’ comp system. Workers’ compensation insurance fraud rings may recruit workers to claim workplace injuries, with a medical provider making a false diagnosis of an injury, and doctors fraudulently treating the injured employees or billing for medical procedures that were never provided.

What Investigators Look For in Workers’ Comp Fraud

Some insurance providers or employers look for “red flags” that may indicate possible fraud. This may be a clue to further investigate the claim, talk to other employees, or use a private investigator to monitor the injured worker. Some possible red flags of workers’ compensation fraud may include:

• No witnesses to the accident
• Employee refusing treatment or examination
• Worker is difficult to contact after filing a claim for workers’ comp
• Injury occurred right before or after a planned vacation
• Injury occurred shortly before the employee was to leave the job
• Employee reported the injury after a poor performance review or workplace incident
• Treatment is inconsistent with the alleged injury
• Extent of injury and accident time frame do not match up

Is Workers’ Comp Fraud a Felony?

Workers’ compensation fraud can be charged as a misdemeanor or a felony, depending on the situation. As a misdemeanor, a conviction for fraud could result in up to a year in county jail and a fine. If fraud is charged as a felony, penalties can include more than a year in prison, fines, and restitution.

Some incidents of workers’ comp fraud can include additional criminal charges. The defendant may face related charges for:

• Identity theft
• Insurance fraud
• Health care fraud

Investigating Workers’ Comp Fraud

Insurance companies and the employer may investigate employees even without indications of claimant fraud. The insurance company and employer have a financial interest in denying workplace injury claims. As a result, they may wrongly deny a legitimate claim for an injured worker. Many employees do not go through the process to appeal the denial, and end up going without the benefits they deserve.

Do Private Investigators Follow Workers After a Claim?

A private investigator may follow the worker with video surveillance. Investigators may also talk to co-workers or neighbors about the worker’s activities. Social media accounts may also be reviewed for evidence that could hurt the worker’s claim. Some of the things investigators look for when an employee makes a workers’ comp claim include:

• Participating in sports or leisure activities
• Doing yard work, home improvement projects, or heavy lifting
• Going on vacation after making a claim
• Social media post showing the cause of the injury that is unrelated to work
• Medical bills for appointments the worker never attended

How Can a Workers’ Comp Fraud Lawyer Help?

Workers’ compensation fraud is a crime . A conviction could result in severe criminal penalties, jail time, and a permanent criminal record. However, a claim of workers’ comp fraud can also make you lose your compensation benefits. For a permanent disability injury, a workers’ comp claim and disability claim may be necessary to help you and your family through a difficult financial situation. With so much at risk, a criminal defense lawyer can help you fight workers’ compensation fraud charges. Avoiding a criminal conviction can help you keep your benefits and avoid a criminal record. A compensation fraud lawyer may also be able to negotiate a plea agreement to reduce charges or get probation instead of jail time.