For employees hurt at work, workers' compensation insurance covers replacement costs for lost wages as well as medical care. In New York, like in many other states, the system is designed to protect workers while also minimizing the risk of fraud. To ensure the integrity of workers' compensation claims, investigators are employed to scrutinize the validity of each claim. Understanding what these investigators look for can help employees navigate the process more effectively and avoid common pitfalls.

The Role of Workers' Compensation Investigators

Investigators play a crucial role in the workers' compensation system. Their primary goal is to ensure that the claims filed are legitimate and that the benefits are only extended to genuinely injured workers. This not only helps prevent fraud but also keeps the insurance premiums in check for employers.

Key Areas of Investigation

Injury Verification

• Consistency of the Injury Report: Investigators compare the employee's report of the injury with medical records and witness statements. Discrepancies can raise red flags.
• Medical History Examination: Prior medical records are reviewed to determine if the current injury could be related to a pre-existing condition.

Employment and Wage Verification

• Employment Status: Verifying the employee's job role, hours worked, and employment history to ensure the claimant was actively employed at the time of the injury.
• Wage Verification: Investigators may check to confirm that the reported wages are accurate, as this can affect the benefits payout.

Activity Level Monitoring

• Social Media Scrutiny: Social media accounts are often reviewed for evidence of activities that could contradict the claimed injuries.
• Surveillance: In some cases, investigators might conduct physical surveillance to observe the claimant's activities, looking for evidence that they are more physically capable than they have reported.

Legal and Procedural Compliance

• Correct Filing: Ensuring that all paperwork and procedures were correctly followed in filing the claim.
• Legal Eligibility: Verifying that the claim meets New York's legal requirements for workers' compensation claims.

How to Ensure a Smooth Investigation for Employees

• Be Honest and Consistent: Always provide accurate information about your injury, how it occurred, and its impact on your daily life.
• Keep Detailed Records: Maintain comprehensive records of your injury, medical treatments, and related expenses.
• Stay Engaged with Your Medical Treatment: Follow your doctor's advice and keep all medical appointments. This demonstrates your commitment to recovery.
• Understand Your Rights: Familiarize yourself with New York's workers' compensation laws and your rights within the system.
• Seek Legal Advice: Consult with a workers' compensation lawyer if you have concerns about your claim or the investigation process.

Common Red Flags for Investigators

• Discrepancies in the Injury Report: Differences in the description of the accident or injury across different reports can signal potential fraud.
• Lack of Witnesses: Claims for injuries that occurred with no witnesses may be scrutinized more closely.
• Delayed Reporting: Failing to report an injury promptly can be viewed suspiciously by investigators.
• Inconsistent Physical Ability: Evidence of physical activity that contradicts the reported injury severity can lead to claim denial.

Frequently Asked Questions 

Q: What should I do if I disagree with the outcome of the workers' compensation investigation?

A: If you disagree with the outcome of your workers' compensation claim investigation, you have the right to appeal the decision. This involves filing a formal appeal with the Workers' Compensation Board in New York. It's recommended to get advice from a lawyer specializing in workers' compensation to navigate the appeals process and improve your chances of a desirable outcome.

Q: How can social media impact my workers' compensation claim?

A: Social media can significantly impact your claim if the content posted contradicts the details of your injury or recovery process. Investigators may use photos, videos, or comments that suggest you are engaging in activities beyond your reported physical limitations as evidence against your claim. It's advisable to be mindful of your social media presence and consider the potential implications of your posts while your claim is being processed.

Q: Can I be under surveillance after filing a workers' compensation claim?

A: Yes, it's possible for investigators to conduct surveillance as part of the investigation into your workers' compensation claim. This may include monitoring your public activities, both physically and online, to verify the severity of your injury. Such surveillance is intended to confirm the accuracy of the claim details and ensure that the compensation is only awarded for legitimate injuries. It's important to consistently adhere to your medical restrictions and guidelines to avoid discrepancies in your claim.

Conclusion

Workers' compensation investigations are a vital component of the system, ensuring fairness and preventing abuse. By understanding what investigators look for, employees can better prepare their claims and avoid common mistakes that could jeopardize their benefits. It's about being informed, prepared, and honest throughout the claims process. If navigating a workers' compensation claim in New York, remember that transparency and documentation are your best allies in ensuring a fair and thorough investigation.

Injured? The Office of Brandon J. Broderick, Workers Compensation Lawyers, Can Help

If the unfortunate happens and you’ve been injured in an accident, don’t go at it alone. An experienced lawyer can advocate for your best interest and pursue fair compensation for your damages. At Brandon J. Broderick, Attorney at Law, you can count on us to work tirelessly for your quality of life. Our long track record of success has helped people like you move forward after sustaining an injury caused by another’s negligence. 

Contact us now for a free legal review.