Health Benefits Claim Benefits Form Concept

The workers’ compensation insurance system in the state of California provides coverage to over 500,000 employers. According to the Workers Compensation Insurance Rating Bureau (WCIRB), this system delivers wage replacement and medical benefits to nearly 800,000 injured workers each year. Sadly, as is the case with any type of insurance, not all claims are authentic, honest and accurate. There is a need throughout California for workers compensation investigations to distinguish the honest from the dishonest and the factual from the fraudulent. Why do certain employees decide to cross over into the “dark side” of dishonest workers comp claims? In most cases, their reason for committing fraud is one of the five reasons listed below.

A Lack of Health Insurance

The U.S. healthcare market is a multibillion dollar industry, but there are still tens of millions of people throughout the country without any health insurance coverage. The sharp financial blow of medical expenses is still going to strike regardless of whether you have insurance or not – especially in the event of an emergency. However, those without medical insurance have nothing to cushion that blow nor would they be able to afford to pay for high-quality care out of their own pockets. This may very well lead an uninsured person to commit fraud with hopes of getting his or her employer to essentially take that blow on their behalf.

Finances Do Not Add Up

The sense of desperation usually settles in when a person is placed in a “do or die” situation with their backs up against the wall without a legitimate escape route available. There is a substantial number of cases in which financial issues lead to fraudulent workers compensation claims. The thought of getting a big settlement as a result of a workplace accident or injury may entice a desperate employee to file a fraudulent workers compensation claim – putting their job as well as their own freedom on the line in exchange for the hopes of a “big payday.”

A Self-Proclaimed Need for Entitlement

“This company owes me!” The false sense of entitlement highlighted in statements like that essentially makes the average employee feel that his or her fraudulent acts are justified. In some cases, this may involve a fairly new employee who seeks it as an opportunity to make a lot of money on the backend without having to work. This is usually why most employers target the newest employees with their own in-house investigations – assuming that the “veteran” employees would never do such a thing. However, a longtime employee who is unsatisfied with their work or the company overall is more likely to file a fraudulent claim – reflecting on the years that they have given to the company in exchange for whatever settlement they hope to receive from it.

The Threat of Downsizing

Another instance where the ugly head of fraudulence may emerge within workers’ compensation claims is when the threat of downsizing arises. As mentioned above, this is also another example of the “desperate times call for desperate measures” mentality. When an employee who may already be struggling financially gets wind of a possible downsizing or finds out that their name is on the layoff list, he or she may consider submitting a fraudulent workers compensation claim to buy themselves some time and remain financially afloat. In addition to covering medical expenses, some may even assume that a filed claim will buy them some more time on the payroll until they are able to find a different job and leave on their “own terms.”

Retaliation for Disciplinary Action

Sadly, there are even experienced professionals who fall for the “don’t get mad – get even” way of thinking after they have been disciplined or reprimanded for one reason or another at work. If they are looking for a way to deliver “payback” to upper management or even the business owner, they may decide to retaliate by filing a fraudulent workers compensation claim with the desire to “make them pay” for their actions.