Understanding the Difference Between Work Comp Fraud and Abuse

Understanding the Difference Between Work Comp Fraud and Abuse

Workers compensation fraud and abuse are each destructive and expensive. Determining the difference between work comp fraud and abuse can be difficult, but it is important. In Missouri, work comp fraud and abuse each carry different legal consequences. Read more to find out exactly what the difference is and some of the most common examples.

Workers compensation claim abuse is defined as any practice that uses the work comp system in a way that is contrary to its intended purpose and/or the workers compensation statute. Abuse can involve the magnification of symptoms that fall short of a lie, or it could involve the exploitation of benefits. While work comp abuse is not a crime in Missouri, it can be cause for work comp benefits to be discontinued.

Workers compensation fraud requires a lie that is material to the attempt to receive or deny workers compensation benefits. The presence or absence of a material and provable lie is the deciding factor between fraud and abuse. Although the lie is key to proving fraud, additional elements must also be present including intent, materiality and a benefit.

Take a look at some of the most common types of workers compensation fraud and abuse.
The following examples are based on actual workers compensation claims.

Self-inflicted or intentional injury—Fraud
A convenience store employee reported that he was assaulted and robbed while taking cash receipts to the bank. The police respond and the workers compensation carrier found the claim compensable and paid for medical treatment and total temporary disability benefits.

As the investigation proceeded, the employee admitted to stealing the cash deposit, and that his friend punched him in the face to make the assault appear more realistic.

The employee was later charged with stealing, filing a false police report and workers compensation fraud. He was ordered to pay restitution to the insurance company for the false claim and reimbursement of the stolen money. In the end, the employee lost his job and gained a felony criminal record, as well as, permanent damage to his vision.

Job-related injury that never occurred—Fraud  
An employee was riding his four-wheeler and jumping over dunes during the weekend and sustained a serious knee injury. The employee waited until Monday morning and then reported that he hurt his knee just after starting work. Co-workers told the employer that he hurt it over the weekend. The employee was subsequently charged with workers compensation fraud.

Malingering or engaging in activities while allegedly disabled—Fraud or Abuse  
An employee injured his back during the course and scope of his employment. While collecting workers compensation benefits, the employee continued to engage in out-of-state rodeo and barrel jumping events. The employee was photographed on horseback in mid-air as he jumped over barrels with his number and name listed in the caption. This evidence enabled prosecutors to charge him with workers compensation fraud. He lost his job and gained a criminal fraud conviction.


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