Proven results in real-world cases

A workers’ compensation claim was filed by an employee alleging a left ankle and foot injury on July 14, 2025, while stepping down from a forklift. Our investigation revealed that the injury actually occurred during a soccer game and was falsely reported as work-related because the employee lacked health insurance.

Welcome to the Coalition Against Insurance Fraud’s first of a four-part series of articles in 2025 on Workers’ Compensation (WC) fraud. The first article, “Claimant Fraud-Case Study”, will be followed by a Premium Fraud-Case Study; an in-depth Provider Fraud Analysis; and then a review of the Best WC Criminal Fraud Statutes.

The insured claimed a medical condition which required 16 hours per day of home health care. The referring claim examiner stated that several red flags existed to include age of claimant not typically associated with the medical claim; cash payments were being made to the home health care provider and the receipts submitted with the claim, seem like duplicates.