By Donna Motley
Director of Claims

The cost of insurance, any kind of insurance, is not cheap. As premiums escalate, there appears to be a new “buzzword” – FRAUD. While the notion of fraud is not new, more and more people are starting to get angry and show interest in putting a stop to it. Some states (not Michigan) have started movements to prosecute those committing insurance fraud. I read recently that Michigan’s automobile premiums had the largest increase in the U.S. in 2013 because of claims paid outside of property damage. That would mean the bulk of payments were for “alleged” injuries and medical care.

While the State of Michigan touts a decline in the number of Workers’ Compensation cases, the dollar figure of those cases continues to increase. That is why we try to be vigilant in detecting fraud. Unfortunately, even if you have a “gut feeling” that a claim is fraudulent, we need hard cold facts to substantiate a denial of benefits. I have to admit, it is a good feeling when you “have the goods” on someone and can confidently deny the claim.

Michigan law states that employers must have Workers’ Compensation insurance coverage. There are people who believe that because we are an insurance company, our goal is to deny all claims and not pay any money. Our position is that if a claim is legitimate, it will be paid. We focus on the injured worker receiving appropriate, quality medical care without being excessive. Medical bills are reviewed and discounted as the State allows.

The insurance industry recognizes multiple warning signs of fraud – and so should you. Be cognizant of the following:

  1. An injury that occurs first thing Monday morning; or late Friday afternoon, but not reported until Monday.
  2. An injury that is reported just prior to a lay-off or pending termination.
  3. An injury that occurred without any witnesses.
  4. An injury that cannot be recreated as the injured worker described; it just doesn’t make sense.
  5. The injured worker’s description does not match the medical history that was taken or the alleged symptoms.
  6. The injured worker is a repeat offender.
  7. The injured worker refuses medical treatment; or only wants to go to their personal physician; or refuses medical treatment following the alleged incident, then seeks their own treatment on their own time.
  8. Late reporting without a reasonable explanation.
  9. While disabled and not at work, the injured worker is never home when you call.
  10. An injured worker quotes the Workers’ Compensation law to you.
  11. An injured worker retains an attorney within days or weeks of the alleged injury.

This is just a sample, and obviously not carved in stone – not all Monday morning injuries are fraud, and obviously many legitimate injuries are not witnessed. But this gives you an idea of certain circumstances that we would consider a red flag.

Let us know any time you have a suspicion and we will investigate.