How to spot a phony comp claim

by Janie Smith12 Aug 2014
There’s a good chance you’ve dealt with workers’ compensation claims during your HR career, but have you ever wondered if the employee’s claim might be exaggerated or not entirely true?

According to a Lexology article by Belinda Winter and Annie Smeaton of Cooper Grace Ward, employers who suspect there’s something wrong with a compensation claim – such as the injury being exaggerated, or having occurred outside of work – can proactively monitor the employee in question and submit a response to the workers’ compensation regulator before the claim is determined.

“Failure to take these steps is likely to result in an accepted workers’ compensation claim and increased premiums for the employer,” the article said.

Winter and Smeaton listed these factors as “triggers for further enquiry”:
  • Reporting an injury late
  • Suffering an injury immediately before retirement
  • Suffering an injury during reasonable performance management
  • Having more than one active claim
  • Having previously rejected claims
  • Suffering an injury that relates to a pre-existing condition
  • Developing new secondary conditions
  • Changing treating medical practitioners
  • Suffering severe injuries from a minor accident
“Employers should proceed very carefully when acting on suspicions as they may be unfounded and in some cases unlawful. We strongly recommend employers obtain legal advice before acting on these suspicions,” said the article.

The lawyers suggested that if an employer believed a claim shouldn’t be accepted, they needed to submit a comprehensive response while the claim was being initially assessed and before it was determined.


  • by Deborah Pearson 12/08/2014 11:22:33 AM

    Having an employee submit what you suspect is a phony Workers Comp claim is one thing. Having the insurance agency agree with you is another. If it's easier for them to simply pay it out than dispute it - guess what their going to do? And it's our premiums that take the hit. I believe insurance agencies need to be more accountable for their decisions and the role they play.

  • by Ron 12/08/2014 11:35:31 AM

    We have proceeded with five of these cases over the years. Two were found in our favour, three we gave up largely because the insurers just werent interested. The turnover in workers compensation insurers means you rarely get anyone who cares and its easier for them to accept a claim than challenge it

  • by Lisa 12/08/2014 3:32:05 PM

    Agree Ron, case workers are often not interested in the challenging cases. We had an employee who was working overseas for 3 months while on workers comp and they wouldn't even question him...not to mention the doctor shopping that goes on.

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