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Questionable Claim

The majority of workers’ compensation claims are compensable or covered claims. However, there is a small percentage of claims reported to employers as work-related injuries or events that qualify as questionable. If these claims are not handled properly, they can result in losses that will affect an employer’s experience for many years to come.

What to do?

The Virginia Workers’ Compensation Commission can impose heavy penalties for failing to report a claim in a timely manner. Therefore, a First Report of Injury should be filed right away. Filing of a report does not create a compensable claim for the employee. Any information regarding the questionable nature of a claim needs to be presented at the same time the report is filed. This would include any evidence an employer discovered investigating the claimed accident and employee, such as:

  • Written statements from witnesses and supervisors along with their names and contact information
  • Any information about the employee regarding pre-existing medical conditions
  • Any recent problems with employer-employee relations
  • If appropriate, photographs of areas where a claimed accident may have occurred that would allow an adjuster to see that a claimed condition did or did not exist are also very helpful

Even if you don’t have investigative materials, you, as an employer, should flag the claim and indicate why you feel it is questionable. Getting this information to an adjuster right away can be critical to completing a thorough review of the claim. If delayed, vital information could be lost. Along with this data, an adjuster will use his/her training and experience to gather additional documentation that may be needed in defense of the claim, should it be litigated. This could include statements from the claimant and potential witnesses, medical records, or additional physical evidence.

If you see potential for a fraudulent claim or have concerns about other fraudulent activities that might be occurring, please contact the Landin claims staff to discuss at your earliest convenience.