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Insurance Related Claims
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Investigation of a subject's activities as related to his or
her present medical condition and alleged physical impairments
is a vital tool to determine further file strategy.
Charles Hess Investigations, a Maryland Detective Agency performs such investigations in a thorough manner through interviews with a claimant's neighbors and other sources of information.
We at Charles Hess Investigations, a Maryland Detective Agency construct an overview of what a claimant's current activities appear to be in relationship to their alleged impairment.
When it is indicated that a claimant's activities may exceed his or her alleged restrictions, or the subject's activities are not consistent with their alleged impairment, surveillance is recommended.
We report our findings in a clear and concise fashion, and also include our professional recommendations to further assist you in determining your possible options.
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| What Is Fraud? |
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Fraud occurs when a person knowingly or intentionally conceals, misrepresents, and makes a false statement to either deny or obtain workers' compensation benefits or insurance coverage, or otherwise profit from the deceit. The key to conviction is proving in court that the misrepresentation or concealment occurred knowingly or intentionally.
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Premium fraud and benefit fraud are the most common types of workers' compensation fraud.
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Premium fraud is usually committed by an employer who misrepresents the amount of payroll or classification of employees, or who attempts to avoid a higher insurance risk modifier by transferring employees to a new business entity rated as a lower risk category.
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A worker who works full time at an unreported job and draws benefits when he or she is supposed to be unable to work, or when a worker fakes an injury; a health care provider or attorney who assists the worker in fraudulent schemes, participates in double billing or bills for services not provided.
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Fraud Indicators
Fraud indicators do not mean fraud has occurred, but they may require a closer review of the claim or application.
- classification codes not consistent
with duties normally associated with the employer's type of
business.
- payroll information on the insurance
application inconsistent with payroll reported.
- much larger premium paid for the
previous year's policy.
- small payroll reported by a large
company or employee leasing company.
- frequent addition and cancellation
of coverage, especially if several business entities or owners.
- injuries occurring late Friday
or early Monday.
- injuries not reported until a week
or more after they occur.
- injuries occurring before a strike
or holiday, or in anticipation of lay off or termination.
- injuries occurring where the worker
would not usually work.
- worker observed in activities inconsistent
with the reported injury.
- worker history of workers' compensation
claims.
- conflicting diagnosis from subsequent
treating doctors.
- any evidence of working elsewhere
while drawing benefits.
- injuries that have no witness other
than the worker.
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