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Red Flags for Fraud

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Red Flags for Insurance Fraud


  • Unwitnessed accidents

  • Delay in notification of injury

  • Injury near a strike, layoff, termination, or right after hiring

  • Claimant immediately gets attorney

  • Hostility, reluctance to provide information,  address (PO Box), phone, medical records

  • History of time off the same time of year

  • History of filing repeated claims

  • Monday morning claims: claimant has an early Monday morning accident (injury may have occurred off the job over the weekend)

  • Being put on probation for poor job performance

  • Recent conflicts with supervisor or coworkers

  • Suggestion from medical sources that a closer look at claimant is needed

  • Claimant cannot be reached because he or she is never home or is reportedly sleeping and cannot be disturbed

  • Repeatedly rescheduling, cancelling, or not attending scheduled medical appointments and/or physical therapy.

  • Anonymous call from outside source or tips from co-workers

  • Conflicting descriptions of the accident/incident between employer’s report and initial medical evaluation

  • Claim is filed immediately before or after a holiday

  • Accident occurs in an area where the claimant would not usually work

  • Family member or known friend recently receiving a comp settlement

  • Doctor(s) cannot find a reason for continued pain

  • Others in the claimant’s department involved in comp claims

  • Alleged injury relates to a pre-existing injury or health problem

  • Claimant being denied time off from work and then reporting a claim

  • Claimant known to have significant hobbies outside work and there is upcoming event

  • Recent family changes, especially a recent divorce

  • Claimant is experiencing financial difficulties

  • Any recent criminal or civil charges filed against claimant

  • Claimant has extensive medical knowledge or has extensive insurance terminology; however, no training in the medical or insurance field.

  • Adjuster intuition

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