Workers’ Compensation Settlement: 3 Important Steps

All insurance claims go through an inspection process before legitimacy can be established but today we’ll be discussing specifically the circumstances of Workers’ Compensation cases. You have to start off with all necessary steps such as verifying coverage, interviews with the employer, employee (bonus points for recorded statements), and any witnesses, and contacting medical providers associated with the claim.

Once all of these steps are done and you find yourself closer to litigation, there are some things you should keep in mind.

Litigation is messy and it’s best to avoid it but insurers have the right to conduct a due diligence investigation on a case that might raise some red flags. If you are tight on time but something doesn’t feel right about the case and you just need more evidence to prove the claim validity here are some steps you can’t miss out on:

Start with the claim’s foundational documents. This ensures that:

• The injury report aligns with medical documentation. Any discrepancies between the injury details and medical diagnosis could signal fraud.
• The timeline of events is consistent. If the worker didn’t alert their manager immediately, it’s worth asking why. Delayed reporting is a common red flag.
• Witness and coworker statements are clear and corroborative. Conflicting accounts or a lack of witnesses for an injury in a busy workplace may indicate issues.

Key Steps Before Finalizing a Large Workers’ Comp Settlement

Surveillance for Workers’ Compensation:

Surveillance provides insurance adjusters with critical insights into a claimant’s daily activities, helping to verify the legitimacy of reported injuries before finalizing a large Workers’ Compensation settlement. By documenting behaviors that may contradict the claimant’s restrictions or injury claims—such as engaging in physical labor or holding a second job—surveillance can uncover potential fraud. This evidence not only supports accurate settlement decisions but also protects insurers from costly overpayments and sets a precedent for thorough claim validation.

Surveillance remains one of the most effective tools for uncovering fraudulent activities. If a claimant reports debilitating injuries but is caught working a second job or engaging in strenuous activities, it can quickly change the trajectory of a case.

This should be one of the first services you conduct on a case because it provides great, recorded evidence of the claimant that cannot be contradicted.

 Independent Medical Examinations (IME):

Claims often hinge on medical diagnoses and treatment plans. An IME provides an unbiased evaluation to confirm whether the injury is consistent with the reported incident and if the treatment aligns with the diagnosis.

Conducting an Independent Medical Examination (IME) before a large Workers’ Compensation settlement provides insurance adjusters with an objective evaluation of the claimant’s injury and treatment plan. An IME can confirm the necessity of ongoing medical care, assess whether the injury aligns with the reported incident, and identify any inconsistencies in the claimant’s statements. This impartial analysis not only helps ensure the settlement is based on accurate medical evidence but also strengthens the adjuster’s position in case of disputes, ultimately protecting the insurer from overpayment and fraud.

Watch the video below for a firsthand account from a Board-Certified Physician, who recounts his experience examining a claimant during an IME prior to a $3.5 million Workers’ Compensation settlement.

Recorded Statements for Workers’ Compensation:

A claimant’s initial statement often sets the tone for the entire investigation. Recorded statements provide a timestamped account of the incident, which can be compared to other evidence as the case progresses.

Recorded statements are invaluable for adjusters investigating Workers’ Compensation claims because they capture a claimant’s account of the incident, injury, and treatment in their own words. Investigators are skilled at recorded statements and will know to question the employer first then the employee and finally the witness.

This detailed account can be cross-checked against medical records, witness statements, and workplace conditions to confirm consistency. If a claimant states they cannot lift objects but is later seen performing physical tasks on surveillance, the recorded statement can serve as evidence to challenge the claim and then the surveillance footage can serve as supportive documentation.

Most importantly, you can ask targeted questions to clarify timelines, prior injuries, or pre-existing conditions, potentially uncovering omitted or conflicting information. This service not only helps validate claims but also creates a documented foundation that can reduce the risk of fraud and ensure that large payouts are justified and accurate.

Honorable Mention: Social Media Investigations

Adjusters often opt to conduct their own social media investigations, browsing platforms like Facebook, Instagram, and TikTok for clues about a claimant’s activities. However, partnering with a professional SIU service provider offers significant advantages. They can perform comprehensive searches across the internet, including the deep web, and cross-reference findings for greater accuracy. Moreover, relying solely on self-conducted investigations can pose legal risks, especially if the case escalates to litigation, potentially leaving the insurer in a vulnerable position.

What is the difference in professional social media research?

• Initial Surface Search: Reviewing Facebook, Instagram, TikTok, and LinkedIn profiles for public posts.
• Deep Web Investigations: SIUs can access information beyond what’s visible to the average user, claimant accounts with different names or hidden connections.
• Cross-Referencing: Investigators connect online activity to real-world actions, such as travel or physical activities inconsistent with the claimed injury

Social media investigations are a relatively fast and affordable tool for verifying the legitimacy of Workers’ Compensation claims before issuing large payouts. These investigations can uncover critical evidence, such as photos or videos of claimants engaging in physical activities that contradict their reported injuries—like attending a fitness class or participating in recreational sports while claiming total disability. Posts and check-ins can also reveal undisclosed travel or employment, which may show information that isn’t found purely from recorded statements or medical records.

What services do you find most effective in your investigations? If you want more options to choose from talk to one of our experts.