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Charles Hess, President - Senior Investigator
Maryland State Police Lic: #106-2688
Tel. (410) 255-4439
Fax (410) 255-4439


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Workers Compensation and Insurance Fraud

Workers Compensation Fraud

Claimant fraud is the most prevalent type of fraud. It is also the type that employers are in the best position to help uncover. Claimant fraud occurs when employees knowingly lie to collect benefits. They may claim an injury was work-related when it wasn’t, exaggerate an injury, or secretly continue working while collecting benefits. Workers compensation fraud comes in many forms.  It ranges from an injured worker receiving benefits and not reporting wages being received from another job, to a physician or health care provider billing for services not performed.  It is the willful intent of an individual to withhold information or provide false information in an effort to obtain workers' compensation benefits.

People who are injured participating in a leisure activity on Sunday and report it on Monday as a work-related injury are committing fraud. Employers who misclassify their employees or pay are committing fraud. Attorneys who solicit a person to file a false claim, or insurance carriers who alter evidence to support a denial of benefits are committing fraud. Fraud affects a company's bottom line, and therefore it affects all the employees. Money that could finance additional staff or increase employee wages must be diverted to pay for increased premiums. Employers pass these increases on to their customers in the form of higher prices. In the end, it is the taxpayers that pay for fraud.

Spotting Injured Worker Claimant Fraud

Some Red Flags Are:

  • Injured worker cannot be reached because their address and /or telephone number has changed or has given a false address or telephone number.
  • Injured worker cannot be reached because he or she is not home or is reportedly sleeping and cannot be disturbed.
  • Injured worker moves out of state shortly after filing claim.
  • Incident occurs immediately prior to strike, layoff, plant closing, job termination or job completion.
  • Injured worker is in line for early retirement.
  • Injured worker refuses (or delays multiple times) diagnostic procedures to confirm injury.
  • Conflicting descriptions of the accident/incident between employer’s report and initial medical evaluation.
  • Injury is not consistent with nature of business/job description.
  • Date, time and place of accident are unknown.
  • Injured worker cannot recall specific details about the injury.
  • Report of injury not timely and immediate.
  • No witnesses to accident.
  • Claimant has multiple claims in state and/or out of state.
  • Tips from coworkers.
  • Employee has a motive to fabricate the claim. Perhaps he or she was denied vacation time, demoted or terminated.
  • Accidents that occur on Fridays or Mondays should raise suspicion, especially if other red flags appear.
  • New employee is more likely to file a fraudulent claim, especially if other red flags appear.

Personal Injury Fraud

By recent statistics ten percent of all property/casualty insurance claims are fraudulent. In one popular scam, the hustler stages an accident at a business in hopes of collecting insurance. It's not a victimless crime; every accident claim filed on your business raises your premium.
Most Personal injury scams fall into these basic groups:
Note there are numerous variations of these scams

  • Slip and Fall - The "customer" stages a fall on a slippery substance spilled on the floor or in the parking lot. It's typically something that would normally be found on the premises: ketchup at a fast-food restaurant, cleaning supplies in a public restroom, produce dropped on the floor in a grocery store. Some con artists find a spill; others create one. Another scam is for a criminal minded pedestrian to slip on your personal property or sidewalk when it has just iced up or just began snowing.
  • Trip and Fall - Con artists often visit stores in search of accidents waiting to happen: an electrical cord stretched across an aisle, a loose weather strip, an obstructed sidewalk, the corner of a carpet rolled up, or merchandise left in the aisle. Then they trip, fall and claim an injury.
  • Yank Down - In this scam, the criminal locates a top-heavy stack of soda cartons, bags of pet food or other unwieldy merchandise, and then pulls it down on top of him or herself.
  • Chew and Sue - At a restaurant, the criminal will put a shard of glass, staple, band aid, or roach in their meal, then claim to have been injured trying to eat it.

*Criminals usually use false names and addresses. When they contact the insurance company to inquire about their claim, they say they have moved; the phone's not connected yet and other deceptions. Often the insurance company is willing to settle the claim quickly to write the claim off the books. Remember you have a right to hire a private detective to investigate the claim.

Auto Insurance Fraud

Fraudulent insurance claims drive up everyone’s insurance costs. Auto accident fraud typically involves staged accidents in which the drivers intentionally collide or involve an innocent driver in a wreck that is made to look like his or her fault. Accident reports may be falsified by criminal parties. Never follow vehicles too closely, particularly when the vehicle in front of you is full of passengers. Watch traffic in adjacent lanes. A common fraud scam is for a vehicle in a different lane to swerve in front of you and immediately brake, typically called “swoop and squat” causing you to rear end that vehicle. A minor fender bender with no visible damage can end up in an expensive personal injury case when least expected.

Usually insurance companies will pay or negotiate a settlement without investigating your contention that you were a victim of fraud. Remember you have the right to hire a detective to prove that personal injuries are fraudulent. Your insurance rate will certainly rise if the insurer pays out. Even minor bumper taps in a parking lot or gas station have been known to cost tens of thousands of dollars in the end and the possibility of cancelled insurance

Please feel free to call Charles Hess Investigations at: 410-255-4439 for a free initial consultation.

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