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Identifying questionable claims

Questionable claims in Workers' Compensation represent a very small percentage of claims; however, according to the National Insurance Crime Bureau (NCIB) the number of questionable claims is increasing despite falling claims frequency. Questionable claims are claims that NICB member insurance companies refer to NICB for closer review and investigation based on one or more indicators of possible fraud.

According to a NICB report, the top referral reason is "claimant fraud" which is two and a half times more frequent than any other cause. If fraud is suspected, it's important to notify the adjuster right away so that a proper dispute for investigative purposes can be filed. The more information provided, the stronger the case.

The second and third top referral reasons are "prior injury/not related to work," and "malingering." An injury not related to work is typically one suffered during a recreational or day off activity but reported as a work injury. A malingerer is someone who has suffered a legitimate injury but continues to feign symptoms, thus collecting benefits long after recovery. These are followed by "working while collecting" and "inflated medical billing."

There are other claims, sometimes referred to as "gray areas" that may not be compensable depending upon the circumstances and the state laws. Some examples are: