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False is Never True: False Claims and Physical Activities

“The truth, the whole truth, and nothing but the truth” – such is the simple standard we have all known since childhood. Nevertheless, some claimants make the criminal’s choice to commit fraud by reporting false claims, exaggerating the extent of their injuries and/or misrepresenting the status of their physical recovery and their ability to return to work. Unfortunately, these individuals take advantage of our system and fraudulently receive benefits.

False claims include those for which a claimant intentionally files a first report of injury (FROI) form for a non-work related injury. For example, a claimant may falsely report that an injury sustained at home or at play was sustained during the course of his/her employment. A false claim may also be filed by a claimant intentionally misreporting accident details. For example, a claimant may falsely report a pre-existing injury, perhaps one sustained and reported in another state, as new injury just sustained with a current Ohio employer. Lastly, false claims include those filed by claimants who stage accidents, including claimants who intentionally injure themselves.

Physical activity cases include those pertaining to claimants who “malinger” – who prefer not to return to work even when they are able to do so. These claimants exaggerate their injuries, falsely reporting that they cannot return to work. They prefer to receive lost time benefits than to earn an honest living.

Some of these claimants are apparently rather convincing actors when they falsely report during examinations by their healthcare providers that they need continued medical treatment. In fact, they may wear their braces or slings, or use their crutches, only as “props” for medical appointments.

A Case In Point

We received an allegation that a claimant was receiving lost time benefits for a falsified assault and that he routinely engaged in several, strenuous physical activities without any apparent physical restriction. Our investigation revealed the subject had furnished no fewer than 17 versions of how he had sustained his injuries in an attempted robbery reported to, and investigated by, local law enforcement. The evidence we secured included statements from multiple witnesses to whom the subject had admitted he had sustained no injury. Additionally, we secured a security guard’s statement that he observed the claimant put on back and leg braces and a sling in a parking lot prior to attending an Industrial Commission hearing. After viewing our surveillance video, a provider concluded the claimant’s “presentation was not true and it was a conscious and deliberate feigning of an illness or disability.” In fact, our investigation proved that while receiving benefits the claimant had continued to work as a self-employed auto mechanic.

When indicted, the subject fled prosecution. However, our Fugitive Task Force located him in Las Vegas, Nevada and secured his extradition back to Ohio. The subject pled guilty to one fifth-degree felony count of workers’ compensation fraud. The court sentenced the subject to serve five years of probation. The court ordered the subject to pay BWC $33,635 in restitution.

Be on the Lookout

Red flags that may indicate a claimant filed a false claim and/or is engaging in physical activities that are inconsistent with his / her reported physical condition:

  • Accident or injury occurs just prior to strike, layoff, plant closing, job termination or job completion;
  • Claimant is in line for early retirement;
  • Claimant admits to a pre-existing injury;
  • Claimant previously described a related accident or injury;
  • Claimant admits he or she did not sustain the injury in course of employment;
  • Claimant admits he or she gave a different account of the accident to medical providers;
  • Claimant admits he or she has filed for benefits in another state;
  • Injury is not consistent with nature of the claimant’s occupation;
  • Claimant cannot recall the date, time and place of the accident;
  • Claimant cannot recall specific details about the accident, injury or medical treatment;
  • Claimant admits he or she intentionally self-inflicted the injury;
  • Claimant is observed engaging in physical activities that are inconsistent with the reported injury;
  • Claimant is observed behaving differently on days he or she receives medical treatment;
  • Claimant is observed behaving differently on days he or she receives attending a hearing; and
  • Claimant relocates out of state or country shortly after filing claim.

If you suspect that a claimant has filed a false claim or engages in a physical activity, let us know. You may report it online at http://bit.ly/reportfraud or you may speak with a fraud hotline agent by calling 1-800-OHIOBWC.

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