Jumping into the heart of the topic, our speakers discussed the importance of adjusters being able to express their ‘articulable suspicion’ when assigning investigations. Hunches alone are not definitive protection against potential privacy violations. Typical articulable suspicions include:
· Unwitnessed accidents.
· The claimant is never available (implying another job).
· Litigation and or criminal history.
· Lots of prior claims.
· Disability exceeds duration guides for non-surgical injuries.
· Tips from co-workers, etc., that claimant is working, engaged in sports, doing home remodeling, traveling, etc.
· Permanent disability is excessive for the nature and extent of injury.
Adjusters are advised to be specific on the referral form so the investigator can focus on the likely activities that will demonstrate fraud or malingering. It is important to engage the whole defense team, including the employer, to identify all red flags. Early and complete investigations are essential. The best cases for subrosa are those when the claimant makes definitive statements that can be rebutted with video evidence.
Fraud in workers’ compensation is very hard to prove. The four elements of “M I L K:” 1. The lie must be material; 2. The claimant has intent to defraud; 3. There must be evidence of a lie; 4. The claimant knew she/he was intending to defraud. If adjusters or employer suspect fraud, they need to have a plan of action to gather evidence, and report to the proper authorities promptly.
Throughout the presentation, Luis from Digistream showed video clips that highlighted situations where subrosa was effective in preventing malfeasance.