How Does a Workers Comp Investigation Work?

In most cases, workers comp benefits can amount to thousands of dollars. It’s no surprise then that some bad eggs will take advantage of the system. To try and prevent this, employers and insurance companies often conduct workers comp investigations, particularly on dubious claims.

If you’re someone who is truly injured, this might seem unfair, especially since employers and insurance companies are known to deny workers comp claims at the slightest doubt. It can also be extremely stressful as one wrong move could cost you your benefits. But due to the rising number of fraudulent workers compensation claims over the past years, it can’t be helped.

So how do you pass a workers compensation investigation?

The best strategy is to be prepared. If you know how workers’ comp investigations work, you’ll know what to expect and how to deal with it. This lessens the risk of doing things that might jeopardize your claim.

To help you out, here are some of the things you need to know about workers comp investigations.

What Counts as Workers Comp Fraud?

In a nutshell, a workers compensation insurance fraud is when an employee willfully lies to claim workers’ comp benefits. The most common examples of which are:

  • faking an injury or illness
  • working while collecting benefits
  • exaggerating injuries to collect more money or prolong benefit payments
  • claiming a non-work-related injury as work-related
  • claiming reimbursement for a medical treatment that you didn’t receive

As mentioned, workers’ comp investigations are conducted primarily to prevent workers’ compensation frauds. But even if your claim is legit, some unintentional actions may give the impression of fraud. So it’s important that you know what counts as such to avoid being charged as a fraudster.

The Workers Compensation Investigation Process

When you file a workers compensation claim, a claims administrator will review the circumstances of your injury. Depending on the evidence presented, they may approve or deny it. But in some cases, they may suspect fraud. That’s when a workers’ comp investigation is launched.

Most insurance companies hire a workers compensation investigator who is usually a private investigator commissioned for such jobs on an as-needed basis. While others have an in-house team dedicated to investigating potential frauds.

Workers’ comp investigators look for evidence using a variety of methods. The most common of which are:

  • Online Surveillance. They will check your social media posts, status updates, tagged photos, and everything they can uncover about you online.
  • Video Surveillance. Workers’ comp investigators are often portrayed conducting surveillance while hiding in their cars and cameras at the ready. That’s not far from reality. It’s not uncommon for workers’ comp investigators to follow you around recording your every movement.
  • Interviews or Other Forms of Direct Communication. Obviously, the best source of information about the injury is the person who got injured on the job. That’s why workers’ comp investigators will sometimes call you or knock at your door to ask questions. You’re not legally required to answer them but denying them an interview won’t help your case.
  • Interviews or Conversations With Your Relatives, Friends, or Co-workers. The people around you are also excellent sources of information about your injury. So expect workers’ comp investigators to also ask them questions.

If the workers’ comp investigator determines that your claim is fraudulent, your claim will obviously be denied. But you can still file an appeal with your claims administrator. If that doesn’t work, you can take your case to court.

Workers Comp Investigations and What They Look For

As you probably have surmised by now, the primary goal of a workers comp investigation is to uncover solid evidence of fraud. That’s why workers comp investigators typically look for the following during the course of the investigation:

  • photos or video footage of the claimant faking the injury
  • witness testimonies that your condition is not as severe as you claim it to be
  • evidence of you not following doctor’s orders
  • proof of inconsistencies in your statement
  • social media posts and comments that prove your injury is fake

Basically, anything that can prove beyond any doubt that your claim is fraudulent will be included in the workers comp investigator’s report.

What Questions Does a Workers Compensation Investigator Ask?

As mentioned, even if your workers comp claim is legit, being questioned on the spot can sometimes make you lose your bearings. It doesn’t help that workers compensation investigators are also known for being intimidating during interviews. That’s why it’s important to know what questions to expect so you can prepare your answers ahead.

Here are some of the most common questions a workers’ compensation investigator will ask you:

  • Can you give a description of the accident in detail?
  • Where did the accident happen?
  • Who are the witnesses (if any)?
  • Can you describe your work, duties, and responsibilities?
  • What’s the nature of your injury?
  • Were company safety protocols followed during the accident?
  • Have you ever filed workers compensation claims before?
  • Can your job be modified?
  • What actions could have prevented the accident?

List down these questions and formulate an answer beforehand. So when the workers comp investigator knocks on your door and starts asking questions, you come prepared. They’re less likely to catch you offguard and make you say things that will cause you to lose your claim.

A tab on a file that says 'investigations'

How Long Does a Workers’ Comp Investigation Take?

Most states require employers and insurance companies to decide on a workers’ comp claim within a reasonable amount of time. Some states also enforce strict timetables for this type of investigation That’s why workers’ comp investigations often last only for a few days or weeks – usually between 14 to 30 days. The faster the workers comp investigator gather all the information they need, the sooner the investigation will conclude. If the insurance company needs more time to gather evidence, they may also ask for an extension.

What To Do When Your Claim Is Investigated

If your claim is being investigated, it’s important to be constantly mindful of your actions. Always assume that a workers comp investigator is watching you. 

For example, if you’re claiming back pain, avoid posting on social media photos of you doing strenuous activities. It might be that you’re on pain meds when the photo was taken. But it wouldn’t matter to a workers comp investigator. If they see you doing things you shouldn’t be able to, your claim might be labeled as fraudulent. 

Even if they tell you otherwise, always keep in mind that the workers compensation investigator is not there to help you win your claim. They are being paid by the insurance company. That should tell you where their loyalties lie. So when dealing with a workers comp investigator, always remember to give consistent answers and be careful with your actions.

Do You Need a Lawyer?

Many insurance companies are known to use workers comp investigations to scare off claimants. Since investigations can take time, many tend to just drop their claim or settle for a much lesser amount.

If you got charged with workers compensation insurance fraud,  they may also pursue a case against you. This is why you need an experienced workers compensation attorney like Victor Malca to fight for your rights. He has been helping injured workers in Florida for almost three decades. He can help refute fraud allegations and defend your claim in court too. Call us now for a free consultation.

(Learn more: Is Workers Comp Taxable? Here’s What You Need to Know)

VICTOR MALCA – Florida Workers Compensation & Social Security Disability Attorney

Victor Malca P.A. has over 27 years of litigation experience in Workers Compensation and Social Security Disability lawsuits. His experience and continued success when fighting for his clients puts him among the most trusted workers’ compensation attorney’s in Florida. He specializes in representing injured workers on compensation benefit cases and disabled individuals claiming lost social security disability benefits.

Book a free consultation today. Our unwavering advocacy for employee rights and privileges are recognized by our past clients across South Florida.

About The Author

is a writer and editor for the Victor Malca Law P.A. website and blog. She enjoys helping people in need with questions about social security disability and workers compensation law. She has a passion for helping those in need and the elderly with accurate legal information that can make a positive difference in their lives.