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Building a strong strategy to successfully litigate the insurer’s side of a fraudulent workers’ compensation claim in Florida is a challenging task. Protecting the company’s interests is paramount, and there are numerous approaches that can provide the proof needed to reduce the damages owed when a worker is suspected of committing fraud.

Developing aggressive and successful approaches for Florida workers’ compensation fraud requires experienced attorneys with a well-established background in presenting solid evidence of wrongdoing. Let’s examine some tactics that can strengthen your arguments against fraudulent claims.

Why Pursue Fraudulent Workers Comp Claims in Florida?

The short answer is that fraud is illegal and wrong. The longer answer is because cases of fraud end up raising costs not only for the insurance company but also employers who must pay for the coverage. Ultimately, employers may decide to make cuts elsewhere to adjust to higher premiums, and those cuts could affect the workforce and consumers.

For example, if fraud is rampant in Florida, insurers must increase their efforts to reduce it and protect their profits so they can continue to provide coverage. Longer investigations delay payments, leaving workers without the support they need. When honest workers are subjected to extensive inquiry, it can cost a company more by increasing their recovery time. If they suffer losses due to the financial burden, they may not return to the company at all.

Fraud hurts everyone in the Sunshine State and must be thoroughly investigated and corrected. Insurers must balance the need to provide benefits with the duty to protect employers, workers, insurance companies, and the economy from fraud.

Oversight for Workers’ Compensation Fraud in Florida

The Florida Department of Financial Services maintains the Bureau of Workers’ Compensation Fraud (BWCF), which investigates claims of fraud by both workers and employers. The right of insurers to determine the validity of an employee’s claim is covered in Florida Statute 440.105. Insurance providers may use a number of techniques to review and verify information, requesting appropriate receipts and other evidence to support claims.

The BCWF can work in tandem with an insurance company to investigate claims of fraud, taking some of the pressure off the insurer. The information they gather can augment a current defense strategy against exaggerated injury claims, questionable explanations, and suspicious medical histories, among other concerning items.

Florida takes insurance fraud claims of any kind very seriously due to the economic impact they can have. New businesses that fear losing revenue to fraud will be hesitant to locate here.

Indications a Workers’ Comp Claim Could Be Fraudulent

Suppose an employee files a workers’ compensation claim that asserts they fell from a ladder at work and suffered substantial injury to both hands and their back. Medical treatment for this can add up to quite a lot, with a potentially lengthy recovery.

However, in an initial review, certain facts come to light that raise red flags for the insurance representative. There may be video footage of the incident that shows the employee falling differently than described. The initial report of the injury may not match the medical evaluation. Something seems wrong, and the insurer investigates.

As the situation unfolds, investigators find social media posts discussing how the employee fell from a ladder while cleaning out their gutters the weekend before their claim. This could indicate a falsified claim attempting to have non-work-related injuries paid for by workers’ comp. Other potential concerns can arise when a worker is seen at another company working while receiving comp benefits.

Investigative Techniques for Gathering Evidence of Fraud

It’s not enough to suspect the worker is trying to pass off a home injury as one happening on the job. The insurer must have substantial proof. This comes from thorough research by experienced attorneys with a broad network of professional investigators and other experts at their disposal.

Private Investigation Services

In our current example, a private investigator could uncover a wealth of information regarding how the employee behaves at home in comparison to their claims of disability. If they injured both hands and their back, activities such as lifting, carrying, sweeping, and even driving could be off-limits.

Providing photo and video evidence of the worker playing ball with their children or mowing the lawn could support a claim of fraud. Investigators may also obtain medical information or speak to the employee’s friends to secure statements about the worker’s behavior outside of work.

A PI can also access an employee’s driving record to determine if they were recently involved in a car crash resulting in similar injuries to the current workers’ compensation claim.

Reviewing Previous Claims

A valuable internal tool for insurance companies will be to look back through the worker’s claim history to assess if they have reported other injuries. Examining those medical and other records could reveal signs of fraud.

Scouring Social Media

There’s a common saying, “The Internet is forever.” An employee might act injured convincingly at work or for a doctor, but then forget to take down pictures of a weekend ski vacation they took right before claiming workers’ comp. Reviewing all social media accounts is a quick way to locate potential evidence that could support your defense when the employee requests fraudulent benefits.

Potential Defensive Approaches for Workers’ Compensation Fraud

Florida provides that an injured worker who provides a false, fraudulent or misleading statement for the purpose of securing workers compensation benefits commits a felony.  Fla. Stat. 440.09(4) and 440.105.  The burden is on the carrier to establish that a false written or oral statement was made and that the statement was made with the intention to secure workers' compensation benefits.

Commons bases for such a defense are when are injured worker denied prior similar injuries to the adjuster, doctors or the carrier’s attorney during a deposition.  Alternatively when the carrier provides DWC19s an injured worker may deny any post accident earnings while they are found to be working.  Establishing this defense requires experiences workers compensation attorneys familiar with the burdens of proof and how particular judges view inaccurate statements.

How To Manage Florida Worker’s Compensation Fraud Cases

When an insurance company needs to determine the true facts surrounding a worker’s potentially fraudulent workers’ compensation claim, they need guidance from attorneys who provide an in-depth understanding of the Florida workers’ compensation system and laws surrounding it.

At Conroy Simberg, we maintain a powerful team of expert resources to investigate and litigate cases on your behalf. Our legal team is skilled at presenting robust evidence demonstrating fraud and minimizing payouts.