Managing workers’ compensation claims is stressful for any business. Nevertheless, employers must continue to do their due diligence in claims investigation, especially when the injury seems unusual. Employers must investigate claims thoroughly and involve all relevant departments in such investigations, including human resources, safety, and legal counsel when necessary. Ohio workers’ compensation is nuanced, which is why employers may need to consult with legal counsel, well versed in Ohio law, at the inception of a claim.
Recognizing signs of a suspicious claim
Research shows that roughly 10% of insurance claims include some form of exaggeration or misrepresentation. This makes it important to pay close attention to each claim.
No single factor is determinative of a claim’s credibility. The following are some common indicators, suggesting a claim may be questionable:
- Frequent short-term injuries that follow a pattern of missed work
- Injuries reported outside of normal work hours, involving unusual circumstances, or occurring in unusual places
- Delays in reporting injuries that do not align with the incident
- Medical records that show inconsistencies with the claimed injury
- Employees with a history of multiple claims, frequent doctor visits or absences, and disciplinary issues
- Injuries reported right after an employee has been disciplined or discharged
Ultimately, determining the root cause of an injury/accident is paramount to workplace safety and the defense of a claim. In every claim, employers should do the following: interview the injured worker and any witnesses; obtain a written incident report from the injured worker; obtain signed and dated statements from the supervisor and any witnesses contemporaneously with the incident; take pictures and/or video of the accident scene; review and preserve surveillance video if available; collect physical evidence where applicable; review your safety protocols; review the personnel (human resource) file; and above all, do not accept a claim until satisfied that the claim is legitimate. When in doubt, deny the claim.
Maintaining a proactive approach
Employers who actively monitor workplace conditions and encourage safe practices may reduce questionable claims. Consistency is the key. Engage your legal counsel to conduct supervisor training and attend workers’ compensation and safety seminars to stay abreast of best practices, current law, and emerging trends.
Responding to claims without compromising safety
Consistent investigation practices supports a safe work environment and ensures effective claims management. Staying up to date on statutory amendments and rule changes helps businesses take an appropriate and expedient response to accidents and reduces potential liability. Ultimately, a consistent approach to claims investigation protects employees as well as your business.