No business wants their WC claim count and dollar amounts to rise, but they especially don’t want to see suspected fraudulent claims ding their WC. Workers’ comp is an insurance program designed to protect and care for employees hurt on the job. So, the burden of proof for fraud always rests with your client, the employer.
The good news is that your clients have tools to avoid workers’ comp fraud. Advise them to 1) implement pre-employment screening; 2) inform new hires about the company’s personal integrity expectations both inside and outside the workplace; 3) establish “medical baselines” to make sure the person hired can do the job they are hired to do; and 4) keep drugs out of the workplace – both legal drugs used illegally and those drugs classified as illegal. These steps are necessary to attempt to “prove fraud” - it is so difficult to do so.
For any prosecution of fraud to go forward, your client must prove intent, which is almost impossible legally. Workers’ cop denials are possible but require documented conflicting statements by the injured employee, written records, investigative reports of witnesses and supervisors, surveillance video(s), questionable medical findings, or co-workers/family reports revealing an employee’s motive or intent. But clients need to realize the even with all due diligence, fraud prosecutions are extremely rare.back