EE avoiding ER calls??

T · June 2003

[font size="1" color="#FF0000"]LAST EDITED ON 07-11-03 AT 02:20PM (CST)[/font][p]EE was moving empty filing cabinets. Claims he hurt his back. Prior to alleged injury he came to work talking about hurting himself at his home while doing house repairs. WC is paying on this because he was actually doing something when he claimed injury.

He tells the doc that he can't drive to work because he is in constant pain and the drive to work takes him 45 minutes. (I found that hard to believe, so I drove the drive and it took me approx. 30 minutes) I myself have witnessed him driving his wife to work only 10 minutes from his own work.

His supervisor, the doctors office and I try contacting him daily, but get no answer or no machine. His supervisor has reached him late in the evening around 9:00 p.m. and on a Saturday morning, but never throughout the day. He also has rent houses as a side business and he has an internet store business.

What can I do if I think this is a "fraud"?????

I also just found out that he is going to school, I believe approx. 80 miles away from his home, to learn to drive 18 wheelers?

I called my insurance man and he says no fraud because he's not actually working or receiving wages. Not really anything the er can do but sit back and watch this guy play the system.

I'll tell you, I might as well claim a back injury, file a wc claim, then collect my benefits and also try to get a college degree doing something.

LindaS · June 2003

Talk to your insurance company and see if they would be willing to send him for an IME. In addition, the insurance company should have the medical information verifying the injury as well as the need for the ee to be off work. I would inform your insurance company of the information you have and let them take it from there.

Mentel · June 2003

I agree. Turn this info over to your insurance company for a fraud investigation. They can track this person for a couple of days and find out what he is doing with his time. I would also have the insurance company do an independent medical review. You have paid the premium, now let them do the work!!!

lorrie · June 2003

I agree that you should contact your work comp insurance agent and tell them everything you know, including what you suspect. They should investigate for fraud and insist on the independent medical exam.

As for the ee avoiding calls: we have a policy that says employees should be in contact with our personnel office at least once per week during their leave of absence. This can even be a brief phone call which includes a medical update from the employee (how are you feeling, specifically) and what other types of activities have you been doing this past week (are you following the doctor's orders, etc.), as well as when is your next medical appt. etc. Sometimes they are very careful of what they say, but sometimes a friendly chat can open a can of worms for them. If an ee fails to maintain the required contact they are written up for job abandonment. This can lead to termination based on our attendance point system.

fmaguire · June 2003

I also have had a similar problem. I did as everyone has said. I contacted our carrier, explained the situation, and gave as much detail as possible. They in turn did an investigation, an IME, as well as Arbitration. In the end, the employee wound up with $12,000.00 (before attorney costs, etc.), and we received his resignation. But before the resignation, the total cost of this clown to our carrier was over $40,000.

This guy was going to college full time while he was suppose to be home with a back injury. Every time he was released to come back to work, he would have another 'accident'. And each time before he had his 'accidents' he would tell a co-worker that he was going to get hurt the following day!!! His past even showed that he had sued every previous employer, but the Commission saw past that and gave him what he wanted. I might add that he was out of work for over a year.

Bottom line, in most states, the laws hold strong for the employee, not the employer. If the employee is reapititious in workman's comp, and/or lawsuits, they know what they are doing, and it can be extremely difficult to catch them.

It's people like that, that are costing everyone else their jobs because of fraud and extensive medical and legal expenses. Companies wind up going out of business. Until we can get some of the laws changed, it will continue.

Balloonman · June 2003

Laws vary from state to state and some are easier to abuse..........this is one of the reasons we check the WC history post offer and have the employee fill out a medical questionairre. While you cannot rescind the offer because they have claims, you can rescind the offer if they falsified the medical documentation. In addition, a very strong restricted duty program goes a long way. It may seem like work at the time, but they pay off in the end.
My $0.02 worth.
DJ The Balloonman

Don D · June 2003

If you have them on Comp and FMLA concurrently, be sure your policy of requiring them to report medical information to you does not violate the clear provisions of FMLA on how often you can do this. FMLA won't allow us to 'harass' comp users as easily as we used to. I agree that the guy is probably at Wal Mart during the day looking at home improvement tools and fishing worms, but don't let it work you into a frenzy. Give it to the insurance company.

mwild31 · June 2003

Something very similar happened to me recently with an employee who slipped and fell at work - spraining his neck. He was consequently placed on a light duty assignment while he recovered, but on the weekends was out off-road motorcycling. We found this out - from the employee himself as he went around telling his 'buddies' at work about his 'great rides'. Washington State arguably has the most liberal, employee-slanted worker comp. benefits and laws in the nation, so imagine my surprise when I called his claims manager and she immediately took our information and called for an investigation. In addition, she reviewed his file and found out that he had been on narcotics for far too long (WA state doesn't like to see narcotics go longer than 6 weeks - as it can lead to addiction & then they would be on the hook to pay for that), so she stopped the payment authorization for that medication. Finally, she stated that restrictions that are put in place by the doctor apply not only to work, but also to home-life - basically, 24/7. Her last statement about the restrictions, caused me a little concern, because it's a position not shared by all claims managers, so we went a step further. We wrote to the attending doctor and stated our position and asked the doctor if they could specify to the injured worker what/how/when the restrictions apply. The doctor readily complied and within two weeks, the injured worker was off light duty and about 2 weeks after that, the claim was closed. I guess the lesson here is to talk to the claims manager and ask for an investigation. Also, don't be afraid to contact the doctor directly - keep it professional and objective, simply stating your concerns and whether or not they (the doctor) believes that more counseling on the restrictions is in order. You don't want to harass the injured worker, but if you are either witnessing facts that seem out of place or the employee themselves is admitting to facts that seem out of place with their injuries, going forward in a professional, objective manner is the best policy - believe it or not, but also for the employee. Our employee, due to the paper work he had received from the doctor's office, truly believed that his restrictions were only for work (the doctor's paperwork is titled "Restricted Work Duties").

ESBVNR

EE avoiding ER calls??

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