WorkCover investigations — discreet and professional

As with any insurance scheme, work cover schemes are prone to exploitation by unscrupulous members who undertake fraudulent activities.

A preventative approach to fraud which actively aims to minimise the opportunities and to discourage persons from committing fraud is obviously best. As part of this type of approach, insurers should:

What does WorkCover Fraud entail?

The definition of fraud

The WorkCover definition of fraud is: ‘obtaining by deception or dishonest means money or any other benefit’.

Worker fraud

There are two categories of worker fraud:

  1. Where the worker does not have a compensable injury or has an injury that does not fall within the ambit of the Act for example:

    • The injury did not arise out of, or in the course of, employment,
    • The worker sustained no injury, but feigns the symptoms to seek compensation,
    • Received an injury during sporting activities, and then claims it occurred at work.

      • In such cases, there is an obvious intent to gain a benefit to which they are not entitled. This type of fraud, if proven, invalidates the whole claim.

  2. “Situation fraud” occurs when the worker has a compensable injury, but at some time during the management of their claim, they obtain benefits to which they are not entitled. This usually involves the provision of misleading information to the case manager. For example:

    • The worker may return to employment while claiming full compensation,
    • May claim for home help when they are capable of looking after themselves,

    While there is still intent by the injured worker to deceive, this fraud does not invalidate the whole claim, but, if proven, may result in a reduction in the claim.

from our files iconFrom our files:

Examples of worker fraud offences

  • An employee claims for an injury that never occurred.
  • A worker claims for an injury that is not related to employment or did not occur out of, or in the course of, employment.
  • Weekly payments are claimed, while the employee is, in fact, earning income from other employment and fails to advise their claims manager.
  • A worker falsely alters medical certificates to obtain compensation or greater benefit.
  • An employee provides false information in relation to a claim for compensation.
  • A worker is engaged in substantial activity contradicting medical certificates/reports.
  • An exaggeration of a disability or incapacity — for instance, an employee may make a costly insurance claim against a firm for an alleged leg or back injury sustained in an apparent 'fall'. Investigation of the matter through discreet surveillance shows that the claimant is, in fact, working on a building site for another company and displays no sign of the injury.

When to investigate WorkCover claims

Fraud is a criminal offence and the onus of proof lies with WorkCover (or the insurer if self-insured) to prove any allegation beyond reasonable doubt. So, as soon as you have identified a potentially fraudulent activity, it is important to engage a discreet, professional investigator to assist you in proving your case.

The CA Investigations team is highly experienced in investigating WorkCover Claims and suspicions of Work Cover Fraud.

Our operatives combine the latest technology with their proven undercover skills to determine if in fact, a fraudulent claim is being sought.

We deliver accurate written reports, along with whatever video and photographic evidence is obtainable, in a timely and efficient manner.

Of course you'll also receive the high level of discretion clients' have come to expect and depend upon from our operatives.

Procrastinating an investigation could cost you thousands of dollars. So don’t delay, if you have suspicions, simply phone us on 0419 717 379 or contact us using a method convenient to you.

What to look out for with WorkCover claims

Unfortunately, there is no “typical persona” for WorkCover fraudsters. Although the majority of people are honest, employers, workers, service providers, agency and corporation staff are able to act alone or together to defraud WorkCover insurers.

Here are some indicators that you can use as a guide in detecting possible worker fraud:

  1. Timing of the incident
    If the alleged injury occurs first thing on a Monday morning, or late Friday afternoon (and is not reported until Monday), there’s a chance that the injury may have been incurred over the weekend during sporting activities.

  2. Change of employment
    If the reported incident occurred immediately before or after the end of a big project, an industrial dispute, job termination, lay-off, at the conclusion of seasonal work or a short-term or contract, you should consider investigating.

  3. Vacation leave issues
    If the alleged injury occurs a few days before or after a holiday, or after holiday leave has been refused the claim might warrant an investigation.

  4. The incident occurs without a credible witness
    Where there was no witnesses to the accident, and the injured worker’s own description does not logically support the cause of the injury; or in cases where the witness has a poor record with compensable injuries and provides a questionable version of the incident, investigation may become necessary.

  5. Claims history
    If the injured worker has a history of numerous suspicious claims, or the medical provider or legal consultant has a past history of handling suspect claims, there is cause for an investigation.

  6. Discrepancies in the reports
    When the worker’s description of the incident conflicts with the medical reports; or the employer’s initial report of the accident does not match the injury or location, or in cases where there are differing descriptions of how the injury occurred, an investigation could shed light the actual events.

  7. Difficulty contacting the claimant
    If the case manager experiences difficulty contacting the worker at home when they are allegedly disabled, or an answering machine or their partner/family members continually act as point of for the injured employee, there may be reason to suspect that the employee is absent from home.

  8. Diagnosis and treatment
    When the injured worker refuses to undergo a diagnostic procedure that will confirm the nature or extent of the injury, or if the worker travels to seek medical treatment in another area from his/her home or workplace, or has no ongoing treatment, an investigation may be called for.

  9. Disgruntled employee
    If the injured worker is about to be or has been retrenched, demoted or passed over for promotion, the claim may be suspect and warrant an investigation.

  10. Referral or tip off
    When information is received from a co-worker, spouse, domestic partner, friend or any other source, that sheds suspicion on the claim, an investigation is in order.

  11. Work history
    If the injured worker has a history of unstable employment or drug and alcohol abuse, or has a poor attendance or sick leave record, an investigation is recommended.

from our files iconFrom our files:

Which WorkCover claims should be investigated

The eligibility of certain claims is inherently tricky to judge, and such claims frequently have substantial cost potential attached. As a result, verification of the circumstances surrounding the claim becomes very important.

Investigation helps to verify existing information on the claim and uncover further information that may be necessary to assist in the determination or management of the claim.

Claims that should be referred for investigation include:

  • The death of the worker
  • Stress and anxiety
  • Working director
  • Heart attack, stress and cerebral haemorrhage
  • Limb and digit amputations
  • Disease claims
  • Hearing loss claims, and
  • Journey claims where there is possible substantial deviation or interruption, or where the deviation or interruption materially increased the risk of injury to the worker.

Need a WorkCover investigation done?

You can depend on the team from CA Investigations to diligently investigate on your behalf and provide clear, accurate, and comprehensive reports — delivered on time.

You'll gain access to the up-to-date progress on your case — available to you 24/7 from anywhere in the world, via your secure log in. Wherever possible your report will include high quality video and photographic evidence as well.

Reliability. Efficiency. Accuracy. Discretion. That's our promise to you. So, if you suspect fraudulent WorkCover claims, don’t wait until it’s too late, contact us using a method convenient to you — or simply call us on (07) 3869 0111.