This list of RED FLAGs is not meant to be all-inclusive, but to be used as a guide.

Contrived Injury or Ambiguous Claim & Suspicious Time Element

  • Date, time, and place of accident unknown
  • Specific details of injury not recalled
  • Report of injury not timely and immediate
  • Conflict in accident description between employer’s report and initial medical evaluation
  • Injury/accident not witnessed, witness accounts inconsistent with claimant’s story
  • Pattern of suspicious claims from Employee Name
  • Anonymous call to the claim’s handler, indicating claimant is not disabled
  • Leads from co-workers suggesting that claimant is active in sports or other activities
  • Monday morning injury
  • Friday afternoon injury not reported until Monday morning
  • Employee has been recently hired
  • Claimant experiences a “seasonal” or recurrent injury
  • Loss reported after employee terminated
  • Claimant in line for early retirement
  • Insured can never be reached at home during the day
  • Claimant who uses a post office box as a mailing address and refuses to divulge residence address
  • Claimant’s spouse being transferred out of state/country or being recently retired
  • Claimant refuses to speak directly to claims examiner, who must go through an attorney
  • Claimant continually must return your calls
  • Difficulty reaching claimant during working hours
  • Claims examiner constantly being told that claimant is sleeping and cannot be disturbed
  • Interview report indicates claimant does not appear disabled
  • Claimant depressed due to recent divorce or financial problems
  • Evidence of multiple disability policies and/or riders on car loans and mortgage payments
  • Not receiving Social Security Disability benefits
  • Claim corrections, erasures, strikeovers, and white outs, especially on attending physician statements
  • Physician and claimant statement where handwriting appears identical, and/or photocopied physician statements
  • Being off work longer than the disability seems to warrant
  • Insured’s daily activities are not consistent with disability
  • Being excessively demanding of a quick claim determination and compensation
  • The accident occurs just prior to a strike, job termination, layoff, or end of project, or at the end of seasonal work; developing disability when a plant shutdown or massive layoff is imminent
  • Third-party accidents with no witnesses
  • The claimant frequently changes physicians, or the claimant has received a release for work that is followed by a change in physician
  • Fellow employees did not witness the accident and/or it occurred in an unusual location
  • Claimant has history of previous claims
  • Conflicting descriptions of the accident exist in the medical history as well as in the employer’s first report of the claim
  • The lawyer and/or treating physician are known for being involved in suspect claims, or the first notice was from an attorney
  • Employee applied for workers’ compensation but was denied.
  • Employee’s regular job is “light duty” according to the U.S. Department of Labor’s Five Degrees of Work

Nature & Extent of Injury, Malingering & Medical Consideration, Professional Consultant Exaggerations

  • Type of injury unusual in the employee’s line of work
  • Injuries do not coincide with claimed circumstances of accident
  • Claimant has soft tissue injury and makes subjective complaints that cannot be objectively verified
  • The claimant is described as suntanned, muscular, with calluses on his hands and grease under his or her fingernails (per rehabilitation report)
  • The claimant has recently obtained disability policies and/or has riders on car loan and mortgage payments
  • The lawyer and/or treating physician are known for being involved in suspect claims, or the first notice was from an attorney
  • Infrequent physician treatments/visits as relates to the diagnosis
  • Claimant refuses IME, or physician will not release medical records
  • The claimant cancels or fails to keep appointments or refuses a diagnostic procedure to confirm an injury or injurious condition
  • The claimant frequently changes physicians or medical providers
  • The claimant has received a release for work which is followed by a change in physician or medical provider
  • Employee fails to return to work on specified date
  • Complaints persist long after the doctor authorizes a return to work
  • Lack of cooperation with rehabilitation personnel
  • Prolonged treatment for relatively minor injury
  • Prescribed treatments and/or medications do not correspond with claimed injury
  • Summary medical bills submitted without itemization
  • Medical bills appear excessive; submitted as photocopies
  • Treating physician/therapist known for handling suspect claims
  • Unnecessary hospitalization
  • Psychological overlays claimed
  • New or additional medical problems attributed to the original injury

Medical Treatment & Claims

  • Diagnosis is inconsistent with treatment
  • Insured’s age inconsistent with diagnosis
  • Conflicting medical reports: IME, emergency room report vs. subsequent office visits
  • Extensive or unnecessary treatment for minor, subjective injuries
  • Injuries are all subjective (e.g., pain, headaches, nausea, inability to sleep, fatigue)
  • Treatment dates appear on holidays or other days those facilities would not normally be open
  • Claimant is immediately referred for a wide variety of psychiatric tests, when the original claim involved trauma only. These claims usually present with vague complaints of “stress”
  • Change in diagnosis
  • Medical reports are identical to other reports from the same physician
  • Incorrect spelling or improper use of medical terms and abbreviations
  • Summary medical bills submitted without dates or description of visits
  • Medical bills submitted are photocopies of originals
  • Photocopies submitted instead of originals of claim forms and bills
  • Missing records, bills, etc., relating to the claim
  • Alteration of bills
  • Physician’s bills show many visits, yet no bills for prescriptions or other related expenses
  • Prescription drugs for suspected drug abuse, such as several prescriptions at the same time at more than one pharmacy, or provider cannot be traced or has no record of patient
  • Whole family receiving frequent/similar treatment
  • Proposed length of disability exceeds recommended by M & R for diagnosis
  • Red Flag Physicians! Doctors who regularly have questionable length of disability
  • Claimant not seen by appropriate specialist (e.g., orthopedist, cardiologist) for diagnosis
  • Claimant has plateaued with physical therapy of other modalities and physician restrictions for 6 weeks or less
  • All soft tissue injuries after 3 weeks
  • Claimant has prior history of extending disability claims
  • Physician approves return to work with limitations
  • Limitations do not match diagnosis (e.g., pulmonary with lifting restrictions)
  • Employee wants to return to work; however, restrictions prevent return
  • Physician continually extends length of disability
  • Workers’ compensation insurer and health carrier billed simultaneously, with payment accepted from both

Claimant Working

  • Difficulty reaching claimant at home during normal daytime hours
  • Frequent interstate relocations while receiving benefits; no permanent address
  • Frequently missed or cancelled doctor or therapist appointments
  • Claimant lifestyle does not coincide with reported/known income
  • Neighborhood canvass reveals claimant works another job
  • Surveillance videos verify employment
  • Verification of employment made with new employer

Legal Considerations

  • Immediate representation by attorney
  • Employee hires an attorney know to handle suspect claims
  • Excessive demands for permanency award
  • Same attorney/doctor combination have previously handled related claims

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