Every workers’ compensation claim is not preventable when you consider that some are deliberate. With due respect to the art and science of safety, preventing real physical accidents and repetitive traumas is essential. However, we need to be mindful of and prepared for the non-accident accident in the claim handling process. Let us refer to these situations as “fact-cidents” since their construct relies on the ability of a claimant to tell a credible story void of facts.
First of all, let’s establish fact-cident detection as an employer’s responsibility. An adjuster with the best list of “red flags” cannot match the gut instinct of an astute employer who knows an employee’s history and extraneous issues and has the opportunity to look that employee in the eye. An unwitnessed fall out of a chair or a bump against a restroom-stall door, or a “giving out” of the knee when turning with a parts tray in hand can be very valid claims… until they are not - mainly because the employer knows something deeper about the employee’s motivation.
The employer must share concerns with the adjuster within the early hours or days of a claim to support heightened focus. Most fact-cidents cannot simply be denied. Very quick work is required. The good news is that fact-cident defense is time-consuming but not complicated. It simply involves obtaining multiple verifications of the story. Just like the old saying “there is no such thing as the perfect crime” there is also no such thing as the perfect false claim. Enough prodding will diminish credibility and isolate the fact-cident for the house of cards that it is.
Quick Tip: Ask, Ask Again and Ask Some More
An injured worker should be required to reiterate their story 4-6 times within the first 48 hours. Here is an optimal sequence:
#1 Report to supervisor who writes down employee’s account
#2 Call in to nurse triage line who interviews and records employee’s detailed account
#3 WC Lead (or risk manager, HR, Benefits, company nurse, etc.) requires discussion and writes down another reiteration of the incident
#4 Treating doctor requires a detailed reiteration of the incident as part of history
#5 Adjuster takes recorded statement of the employee’s account
#6 Adjuster and employer-leaders separately circle back to employee after doctor visit to get employee’s version of the doctor’s assessment
Compare and Share
With these multiple stories and queries, the true detective work begins in comparing and sharing employee versions of the accident. Fact-cident claimants notoriously will assume what certain parties want to hear and adjust stories accordingly. They also may enhance their story gradually with each reiteration. After medical visits, they often alter what actually happened or was said by the doctor. Sadly enough, many seem to think they can play all sides to the middle with no cross-checking among the crowd. Don’t let that happen!
The investigative test relies on comparing all versions and then, as might be indicated, sharing with other parties. For example, if the initial supervisor and HR manager reports mention non-falling incident with ankle pain but the version to the doctor claims a fall to the floor adding hip, back and elbow pain you have an immediate piece of evidence validating suspicions. You can confidently invest and engage denial, defense, IME, surveillance, field nurse, et.al.
Inconsistencies can also be presented to the doctor for review and revision or re-exam to correct any false reliance on claimant’s story. If possible, with cooperative providers, the early internal reports can be shared with treating doctor in real time so he/she can diligently test the employee’s credibility against other statements.
An even more powerful reason to quickly collect and solidify various versions is to avoid future attorney representation and fact-cident influencing. Worst case scenario with lack of early employee statements is that an attorney gets to coach the employee into a tighter self-serving story later on.
Conclusion
When you suspect an accident is actually a fact-cident, don’t accept any aspect at face-value. During the claim handling process, put the time in to either confidently validate/pay the claim or justify heavy investments in defense.
As a bonus, from the big-picture perspective, this type of consistent diligence establishes a general no-nonsense workplace attitude and culture when it comes to workers compensation. Specifically, it will make employees think twice about conjuring up a fact-cident!
