EFFECTIVE SURVEILLANCE REDUCES THE PAID COSTS ON CLAIMS
Experience has shown us that some injured workers will prolong their return to work by malingering or exaggerating their disabilities. Surveillance investigations should be initiated when you have good reason to believe the worker is misrepresenting his / her disability, and when visual evidence can be utilized or be a benefit in closing or managing the claim. In those instances, conducting covert surveillance and gathering video evidence of the injured worker’s disability and activity level is necessary to manage the claim effectively and avoid paying undeserved benefits.
Surveillance video may also be beneficial – or necessary in some cases for establishing evidence that supports a fraud investigation and resulting in criminal prosecution. The goal in the fraud investigation is to determine whether fraudulent activity has occurred and to identify the course of action that should be pursued. That may lead to a recovery method that would include collection of monies owed, or civil / criminal prosecution.
There are three main categories of fraud investigations: worker, employer and provider. You may recognize the indicators when dealing with the injured worker, but there are other red flags that may alert you to the need for further investigation of other types of possible fraud.
Criminal prosecution differs from the WCB Hearing arena, in that we must establish Proof Beyond a Reasonable Doubt rather than a preponderance of evidence (which may suffice at the Hearings level). There must be an opportunity for fraudulent activity.
CHARACTERISTICS OF SURVEILLANCE “HIGH HIT” RATIO CASES: LIKELY TO OBTAIN RESULTS
CHARACTERISTICS OF SURVEILLANCE “LOW HIT” RATIO CASES: LESS LIKELY TO OBTAIN RESULTS