Red Flags Of Employee Workers’ Compensation Fraud In Florida

Statistically, only about 2 or 3 percent of workers’ compensation claims involve employee fraud. However, that figure doesn’t stop Claims Examiners from using fraud as an excuse to deny claims. That’s especially true if the job injury claim includes one of the red flags listed below. Since insurance company interests dominate the initial claim review process, most Claims Examiners look for ways to reduce or deny workers’ compensation benefits, like medical bill payment and lost wage replacement.

Injured workers badly need these benefits, so they can return to work as quickly as possible. A Tampa workers’ compensation lawyer helps make that happen. In the end, that’s the outcome everyone wants. Attorneys know how to take broad agreements on such general principles and translate them to specific agreements on specific items, such as the amount of financial benefits injured workers need and deserve.

Off-Hour Injuries

Many Claims Examiners narrowly interpret the work-related rule to mean that the injury must occur while the victim is on the clock. So, if the injury occurred after hours, especially on a weekend, Claims Examiners often reach for the red “Denied” stamp without looking further into the matter.

The work-related rule is much broader. Usually, if the victim was doing anything that benefited the employer, the injury is work-related. If Tom hurts his knee at a company softball game, his injury is most likely work-related. The company benefits not only from the free advertising at the game, but also because healthier employees are usually happier and more productive employees.

Additionally, the day of a doctor visit isn’t necessarily the day of an injury. That’s especially true in hearing loss, repetitive stress injury, and other occupational disease claims. In fact, after-hours medical visits are very common in these situations. Most victims don’t want to miss work to see doctors.

Medical Issues

Usually, Claims Examiners look for two kinds of fraud in this area: unreliable doctors and exaggerated injuries.

Unreliable doctors are a serious problem in many states. Florida is different. Usually, job injury victims must see company doctors. However, that doesn’t stop Claims Examiners from scrutinizing medical treatments in Florida. If the doctor’s treatment deviates from the standard of care, even a little, the Claims Examiner usually denies the claim.

However, not all injuries are created equally. Some injuries are more severe than others. They don’t all neatly fit into tables that an insurance adjuster who knows nothing about the victim’s injury probably created.

Roughly the same thing applies to exaggerated injuries. Most injured victims have good days and bad days. On a good day, they might feel almost like themselves. On a bad day, they may be unable to get out of bed. Workers’ compensation claims aren’t based on good days or bad days. Instead, they’re based on an average of good days and bad days.

Sometimes, a Tampa workers’ compensation attorney advocates for victims at the initial stage. Typically, however, such advocacy is wasted. Claims Examiners are often determined to deny these claims no matter what. Things are different at a hearing before a neutral Administrative Law Judge. ALJs consider all the facts, and not just some of them.

 Connect With a Hard-Working 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. We do not charge upfront legal fees in these matters.

Source:

nhcaa.org/tools-insights/about-health-care-fraud/the-challenge-of-health-care-fraud/