Claims Investigator

Workers compensation is offered to workers who are injured while performing their normal job duties. But what if the insurance company suspects the employee is lying or exaggerating their work injuries? Workers' compensation investigators are tasked with investigating workers compensation fraud, either perpetuated by the employee, the employer, or the health care provider.

Tasks of a claims investigator

If an employer or an insurance company suspects work comp fraud they will hire a private claims investigator to conduct surveillance of the worker's activities. Surveillance may be requested whether the claim has been voluntarily paid or if the work comp claim has been denied. The goal of the investigator is to find incriminating evidence against the worker.

Claims investigators may use a wide range of techniques to find evidence for their case including searching social medial sites, such as Facebook, talking to friends and neighbors, following the worker or calling the worker and requesting information. Workers compensation claims are often denied after a claim's investigator finds evidence that the worker is performing activities beyond the restrictions set by their doctor.

Evidence of workers' compensation fraud

The claims investigator is looking for evidence of fraud. Common signs of fraud include a post termination claim, frequent job changes, pre-existing medical conditions similar to the work injury, no witnesses to the injury, and conflicting descriptions of the injury. Red flags can also be raised if the worker refuses medical treatment or waits to report the injury.