• No Employment Development Department (EDD), unemployment or
temporary disability is being paid.
• Information is received that the employee is working.
• Information is received that the applicant participates in sports or other
activities that could have caused the alleged injury.
Adhering;to;some;overall;best;practic-es will significantly improve the validity
of;a;case.;Make;sure;to;obtain;authoriza-tions for release of medical and employment records, request all records from
the medical provider, do not include date
of loss in records requested, closely review all documents and obtain records
referred to in current records, and obtain
complete written statements. If the claimant will not provide or counsel will not
allow a written statement, request that
the defense attorney perform a deposition if it has not already been done.
Once the investigation is complete,
the next step is an evaluation, typically
by a district attorney and the department
of insurance to determine the viability
case may then take three to six months
to build, part of which is to determine
whether the situation involved abuse or
fraud. The case is then presented to a
judge, and in California the department
of insurance makes the actual arrest.
Finally, once the decision is made to proceed, it is advisable to take an aggressive
defense posture. If the case appears to be
fraudulent, have counsel make clear at
the beginning that the company will try
the case. Insist upon accurate and complete discovery. Closely review all discovery responses, especially verifications.
Discuss with defense counsel the strate-gies;for;taking;the;offensive;in;litigation.
Also, keep in mind that regardless
of what happens in the criminal pros-
ecution of a fraud case, the underlying
Workers’ Compensation claim must still
ministration of the compensation claim
must continue according to Workers’
Some claims may appear minor at first
and then subsequently escalate, resulting in very costly surgery and indemnity
the role of the special investigations unit
is absolutely critical in gathering accurate
information quickly and helping to make
strategic decisions early on that will impact the overall outcome of a claim.
Stacey Golden, director of claims for Keenan,
is responsible for leading the firm’s SIU/Fraud
Unit, training and development, and vendor
management. Golden is also an advisor to
the California-based Employers’ Fraud Task
Force and a guest lecturer for the Insurance
Educational Association (IEA). She has more
than 20 years experience and is certified
by the IEA, Workers’ Compensation Claims
Professionals association and California
Office of Self Insurance Plans.
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