Fast Food Employee’s Work Comp Claim Doesn’t Stack Up

This case involves a fast-food employee who reported a slab of ice fell on her right arm. She was taken off work and treated for many months, yet continued to allege severe ongoing pain. Interestingly, the worker’s diagnostic imaging tests were normal, with no significant findings. 

During one medical visit, her physician was unable to examine her arm/hand due to her hyper-sensitivity to touch and intolerable pain being greater than 10/10. After this exam, the ICW Group Nurse Case Manager and physician discussed the encounter. They agreed it appeared she was not forthcoming about the nature and extent of the alleged injuries, and it was agreed that a deeper investigation was warranted.

Surveillance doesn’t lie

Surveillance was immediately initiated, and the claimant was observed doing yard work and mowing the grass. She was able to use both hands to operate the lawn mower, lift and empty the grass-clipping bag, use a shovel, and move an outdoor metal table. She was not wearing a brace during surveillance and exhibited no difficulties ambulating.

ICW Group’s Special Investigations Unit (SIU) quickly shared the surveillance results with the worker’s physician. The doctor’s newly revised report indicated the worker was capable of working full duty and had reached what physicians call “Maximum Medical Improvement.” Further, the doctor reported that the worker had demonstrated she had not been forthcoming regarding her case. He discharged her due to noncompliance with the plan of care.

ICW Group referred the matter to the California Department of Insurance and the Shasta County District Attorney’s Office. Following a criminal investigation, the worker was charged with multiple felony violations. Ultimately, the worker was found guilty and ordered to pay more than $65,000 in restitution and court fines and serve probation.

Anti-fraud unit helps detect, deter, and defeat fraud

Learn how ICW Group’s coordinated approach between Triage Examiners, Claim Examiners, Nurse Case Managers, and SIU staff can support your workers’ compensation program. Visit our Policyholder Center for more information.

Brian Biggs
Brian Biggs
Brian serves as the Manager of ICW Group’s SIU team. He has been in the industry since 1997 in a variety of roles including Claim Professional, SIU Investigator and SIU Director. Brian has previously been elected President of multiple anti-fraud industry trade organizations and is joining the Board of the Anti-Fraud Alliance in early 2024. He has attained more than fifteen professional designations including the CPCU, Certified Insurance Fraud Investigator and Associate in Risk Management. Brian is frequently asked to present at conferences and industry meetings and revels at these opportunities. Brian welcomes the opportunity to speak with anyone, anywhere, anytime about insurance fraud (and all manner of BBQ).

Related Articles

ICW Group’s Anti-Fraud Team is Top of Its Field

ICW Group remains at the forefront of industry trends, scams, and exposures within the insurance community. Our entire Special Investigations Unit (SIU) staff are members of multiple anti-fraud trade associations,...

Watch for These Common Scams

Did you know the first recorded scam dates back to 300 B.C.? That’s right. Over 2,000 years ago! It's believed that Hegestratos, a Greek sea merchant, purchased an insurance policy on...

What Motivates Workers’ Compensation Fraud?

Fraudulent claims can have a tremendously adverse impact on a business’s profitability, the morale of the employee base, and the long-term viability of your operation. Understanding what motivates an...