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Tampa Workers' Compensation Attorney / Blog / Workers Compensation / How Does The Commission Prove Workers’ Compensation Employee Fraud?

How Does The Commission Prove Workers’ Compensation Employee Fraud?

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Almost all workers’ compensation claims in Florida are valid from head to toe. The job injury fraud rate is only about 1 or 2 percent. However, insurance industry groups, like the Coalition Against Insurance Fraud, claim the workers’ compensation fraud rate is between 15 and 20 percent. As a result, insurance companies aggressively investigate suspected employee fraud matters. These investigators often fail to appreciate the difference between a false statement and a fraudulent statement.

Indeed, a workers’ compensation fraud allegation is often a bluff. The insurance company hopes that the job injury victim will back down and settle the claim for less than it’s worth. A solid Tampa workers’ compensation attorney is not intimidated by insurance companies or their threats. That’s especially true regarding fraud allegations. As outlined below, these matters have a number of moving parts. So, a Tampa workers’ compensation lawyer keeps working for you, even if the odds seem long.

Employee Fraud Red Flags

Before we look at the elements of a workers’ compensation fraud case, let’s look at what draws an investigator’s attention to the case in the first place. Frequently, investigators look for red flags, such as:

  • No other witness to the injury,
  • Delayed injury report,
  • A late Friday or early Monday injury,
  • Injury at an unusual location, like a branch office,
  • Occurrence shortly before a holiday, strike, or possible termination.
  • Conflicting medical evaluations, and
  • Evidence the employee was working elsewhere while injured.

Investigators also look for red flags which indicate possible employer, attorney, and medical provider fraud. However, as mentioned above, employee fraud investigations are much more aggressive than the ones in these other areas.

Willful Statement

A willful statement is the first element of a workers’ compensation fraud claim in Florida. Basically, willful is one step short of malicious. Alleged fraudsters must intentionally make false statements which are calculated to produce a certain result.

Accidents happen. That’s obviously the case, or the victim could not be filing a workers’ compensation plan to begin with. Insurance companies intentionally force victims to fill out long forms when they are not feeling well. So, the potential for accidental incorrect responses is high. This potential is even higher if, as is often the case, English is not the victim’s first language.

Additionally, willfulness implies intent to defraud. The workers’ compensation system is so complex that it’s difficult to prove the victim understood the process. It’s even more difficult to prove the victim intended to cheat the system.

False Statement

The false statement usually relates to the extent of injury, the amount of medical bills, or the victim’s AWW (Average Weekly Wage). This element of a workers’ compensation fraud claim is pretty much the only one that is relatively straightforward, at least as far as the insurance company is concerned.

To Receive Benefits

Finally, the insurance company cannot simply present circumstantial evidence on the above two points and rest its case. Instead, the insurance company must prove the victim willfully made a false statement in order to receive benefits s/he wasn’t entitled to. There are a number of reasons, aside from obtaining benefits, that a person might willfully make a false statement in these situations. The insurance company cannot simply narrow the list. It must definitively prove intent.

Count on a Dedicated Hillsborough County Attorney

Injury victims are entitled to important financial benefits. For a free consultation with an experienced workers’ compensation lawyer in Tampa, contact Kobal Law. Virtual, home, and hospital visits are available.

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