What Are Workers Compensation Investigations?

Workers’ compensation investigations are comprehensive inquiries initiated by an employer’s workers’ compensation insurance company to assess the validity of claims made by employees who have suffered injuries or illnesses on the job. They are meant to prevent fraudulent activities.

Why Insurance Companies Initiate an Investigation

While not every workers’ compensation claim undergoes a thorough investigation, many employers’ insurance companies do initiate investigations as a standard practice.

The decision to investigate often depends on various factors, including the severity of the injury, the circumstances surrounding the incident, and the nature of the claim.

High-dollar claims, claims with ambiguous details, or those involving extended periods of disability may be more likely to prompt an investigation. Additionally, if there are suspicions of fraud or inconsistencies in the claimant’s statements, an investigation becomes more probable.

Types of Workers Compensation Investigations and What They Look For

Workers’ compensation investigators, often employed by insurance companies or third-party agencies, are tasked with collecting and analyzing evidence related to a claim. Here are the key areas they focus on and what they typically look for:

Medical Investigations

• Objective: Verify the medical aspects of the claim.
• Focus Areas: Severity of the injury, the necessity of medical treatment, and the correlation between the injury and work-related activities.

Surveillance Investigations

• Objective: Confirm the accuracy of information provided in the claim.
• Focus Areas: Monitoring the claimant’s activities to ensure that reported limitations align with their actual capabilities, identifying potential exaggerations or inconsistencies.

Witness Interviews

• Objective: Gather statements from coworkers, supervisors, and other witnesses.
• Focus Areas: Establishing the facts surrounding the injury, gaining additional perspectives on the incident, and corroborating or refuting the claimant’s account.

Background Investigations

• Objective: Examine the claimant’s background for relevant information.
• Focus Areas: Any pre-existing conditions, history of similar claims, or other factors that may impact the legitimacy of the current claim.

Independent Medical Examinations (IME)

• Objective: The insurance company may request an unbiased medical assessment.
• Focus Areas: An independent evaluation of the claimant’s injuries and medical condition to verify the accuracy of the reported medical information.

Records Review

• Objective: Analyze relevant documents related to the claim.
• Focus Areas: Ensuring consistency between medical records, incident reports, and the claimant’s statements and identifying any discrepancies.

Social Media Investigations

• Objective: Scrutinize the claimant’s online presence.
• Focus Areas: Inconsistencies between social media activity and reported limitations, potential evidence of activities that contradict the claimed injury or disability.

What Can I Do if My Claim Is Denied Based on Investigation Findings?

If your Pennsylvania workers’ compensation claim is denied based on investigation findings, you have the right to appeal the decision. Here are the steps you can take:

1. Review the Denial Letter

Carefully go through the denial letter to understand the specific reasons for the rejection. This information will guide your next steps.

2. Consult an Attorney

Consider consulting an experienced Philadelphia work injury attorney. They can provide valuable insights into the appeal process, help you understand your rights, and guide you through from beginning to end.

3. File a Petition to Appeal

You can file a petition with the Pennsylvania Bureau of Workers’ Compensation.

4. Gather Evidence

Collect any additional evidence that supports your claim. This may include medical records, witness statements, or other relevant documentation that addresses the concerns raised during the investigation.

6. Attend All Hearings

Attend all hearings scheduled as part of the appeal process. During these hearings, you or your attorney will have the opportunity to present your case to a judge, and the employer or their insurance company will present their arguments.

7. Negotiate or Mediate

In some cases, negotiations or mediation sessions may be scheduled to reach a settlement. Your attorney can help facilitate these discussions and advocate for your best interests.

8. A Decision Will Be Made From A Judge

A workers’ compensation judge will review the evidence presented during hearings and make a decision. If you disagree with the judge’s decision, you can further appeal to the Workers’ Compensation Appeal Board.

9. You Can Appeal to the Commonwealth Court If Necessary

If necessary, you can appeal to the Commonwealth Court if the Workers’ Compensation Appeal Board’s decision is not satisfactory. This is typically the final level of appeal within the workers’ compensation system.

10. Consider Other Legal Options

If all else fails, and you believe your rights are not being upheld, consult your Philadelphia personal injury attorney about potential legal actions outside of the workers’ compensation system.