10 Disability Claim Red Flags You Can’t Miss

When it comes to managing disability claims, timing and accuracy are everything. A single missed red flag can lead to prolonged claims, inflated payouts, or worse—a fraudulent case slipping through the cracks. For risk managers, claims adjusters, and claims managers alike, identifying early warning signs is critical to ensuring fair outcomes and controlling exposure.

This guide covers 10 of the most common disability claim red flags. Whether you’re working with short-term or long-term disability claims, these red flags will help you triage risk, prioritize investigations, and protect your bottom line.

Delayed Reporting of Injury or Illness

Time is a key variable in legitimate claims. When there is a significant delay between the alleged onset of a disabling condition and the date it is reported, it raises a red flag. Employees with legitimate injuries typically report them promptly. Delayed reporting may suggest:

The incident didn’t occur at work

The condition is not as serious as claimed

The claimant is attempting to align the leave with other life events (e.g., termination, vacation)

Pro tip: Always ask for a detailed explanation for delayed reporting and check for inconsistencies in the timeline.

Inconsistent or Vague Medical Documentation

Medical records are the backbone of any claim especially disability cases where benefits are large and prolonged throughout the time of the injury and recovery. Red flags in this area include:

• Diagnoses that are overly broad or non-specific
• Lack of objective medical evidence
• Frequent changes in providers with no clear medical justification

Monday Morning Claims

Claims reported first thing Monday morning can signal that the injury or illness occurred over the weekend and may not be work-related. Similarly, claims filed immediately after holidays or long weekends deserve extra scrutiny. Click here to read a blog where we go in-depth all about Monday morning injuries.

What would a potential Monday morning disability claim look like?

A “Monday morning” disability claim refers to an injury reported first thing on Monday that allegedly occurred at work—but may have actually happened over the weekend. These claims can raise suspicion due to the timing and lack of witnesses or incident documentation.

Red flags often include:

• The injury wasn’t reported immediately or occurred without witnesses.
• The nature of the injury (e.g., sprains, back pain) is hard to verify objectively.
• The claimant has a history of prior injuries, absenteeism, or performance issues.

Example:
An employee returns to work Monday and reports severe lower back pain, claiming they “tweaked it lifting boxes” last Friday—but no coworkers recall the incident, and there was no report filed before the weekend. The employee had just worked a side job moving furniture on Sunday, which was mentioned in a social media post. Not all Monday claims are fraudulent but timing, context, and corroboration are key to determining credibility.

4. Claim Filed After Disciplinary Action or Job Dissatisfaction

Workplace tensions often serve as a backdrop to questionable claims. If an employee files a disability claim shortly after receiving a poor performance review or disciplinary notice, it may be a form of retaliation or a way to avoid termination.

5. Excessive or Unusual Travel While on Leave

If a claimant is too disabled to work but well enough to travel extensively, it raises concern. While travel alone doesn’t disprove disability, it can be inconsistent with reported limitations especially if the condition cited involves pain, fatigue, or restricted mobility.

6. Incompatibility Between Stated Limitations and Daily Activities

One of the most effective tools for identifying red flags is comparing a claimant’s reported restrictions to their known or observable activities. For example, a claimant who reports debilitating back pain but is seen lifting heavy items or engaging in vigorous exercise likely has inconsistencies to explain.

7. Multiple Prior Claims or Frequent Transitions Between Disability and Work

Some claimants develop a pattern of moving in and out of disability status, often with vague or subjective diagnoses. While not inherently fraudulent, a pattern of repeated disability leaves can indicate deeper issues or potential malingering.

8. Disability Claim Coincides with External Life Events

If the timing of a claim conveniently aligns with a major life event such as a spouse’s relocation, upcoming maternity leave, or impending retirement, the motivation for filing should be further explored. This doesn’t negate a legitimate claim, but as always, context is important.

9. Lack of Engagement in Treatment or Rehab

Legitimate claimants usually engage proactively with their treatment plans and show interest in recovery. When a claimant misses appointments, resists referrals, or avoids prescribed therapies, it may suggest the disability claim is being used as a means to delay returning to work.

10. Medical Provider with a Reputation for Questionable Claims

Not all healthcare providers approach disability evaluations with the same level of objectivity. Some clinics and physicians develop a pattern of supporting fraudulent claims, often producing inflated work restrictions. If a claimant’s primary medical provider has a history of such practices, it’s worth digging deeper.

Example:

Take this example, a local clinic known for consistently diagnosing patients with vague conditions like “chronic pain syndrome” without conducting thorough evaluations or providing objective medical evidence. In one case, a claimant submitted a disability claim supported by this clinic’s documentation, which lacked diagnostic tests or detailed assessments. Upon further investigation, it was discovered that the clinic had a history of similar practices, raising concerns about the legitimacy of the claim and even warranting further investigation into the clinic’s shady practices. If there are patterns of questionable practices, consider getting a second opinion or an Independent Medical Examination (IME).

Pro Tip: Cross-reference the provider’s reputation with past claims history (this is where AI can come in handy!).

It’s important to remember that these red flags are not proof of fraud but rather indicators of potential issues. Any one red flag on its own isn’t necessarily a raise for concern it’s when multiple flags start to add up that the likelihood of fraud increases.

In claims management, distinguishing between high-risk cases allows for faster resolution. Contact us today to learn how our nurse case managers and clinical review experts can help you build stronger claims from day one.