How to identify fraudulent workers’ comp claims

What is workers’ compensation fraud?

Worker’s compensation fraud is when a person dishonestly obtains a payment or other benefit under the Workers’ Compensation and Rehabilitation Act 2003 (Qld) (the Act).

Worker fraud includes:

• Claiming for an injury that did not occur, or happened outside of work;
• Exaggerating an injury;
• Earning a wage while on income maintenance and not declaring it;
• Receiving Centrelink payments while on income maintenance and not declaring them;
• Altering medical certificates; or
• Providing false or misleading information in relation to a claim for compensation.

Employees found guilty of workers compensation fraud can be liable for criminal convictions, fines up to $55,000 or a maximum of five years imprisonment. They can also be ordered to pay back any money obtained dishonestly and costs incurred by WorkCover Qld to investigate and prosecute the matter.

What should an employer look out for?

Any of the following occurrences may be an indication of a fraudulent claim and serves as a warning to the employer to follow the claim closely:

• Did the employee report the incident immediately or was there a delay?
• When did the injury occur? If it happened on a Monday, the alleged injury could have occurred on the weekend.
• Can the employee remember the exact details of their injury?
• Has the employee changed their story as the claim progresses?
• Are there inconsistencies in the employee’s story about the accident?
• Has the employee developed new secondary conditions?
• Did the injury occur immediately before retirement?
• Did the employee suffer severe injuries from a minor accident?
• Were there any witnesses when the injury occurred?
• Did the injury result from reasonable management action taken in a reasonable way to manage the employee’s performance?
• Is the employee having financial hardships at home?
• Does the employee have more than one active claim?
• Does the employee have previously rejected claims?
• Does the injury relate to a pre-existing condition?
• Has the employee changed their treating medical practitioner?
• Is the employer having difficulty communicating with the employee out of work and at home?
• Is the employee missing medical appointments?
• Has the employer received reports the employee is doing strenuous work at home?

If an employer suspects an employee has lodged a workers’ compensation claim that should not be accepted they should contact WorkCover Qld immediately to get advice on the best way to handle the claim.  If possible, the employer should submit a comprehensive response while the claim is being initially assessed and before it is determined.

Legislation

Workers’ Compensation and Rehabilitation Act 2003 (Qld)

Further information

If you need any assistance drafting your response to WorkCover or conducting a workplace investigation, contact us for a confidential and obligation-free discussion:

Disclaimer

This article contains general commentary only.  You should not rely on the commentary as legal advice.  Specific legal advice should be obtained to ascertain how the law applies to your particular circumstances.

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