DON’T BE A RED FLAG: 25 Reasons to Question an Alleged Work Injury


25 Reasons to Question an Alleged Work Injury

You got hurt at work. You reported the injury. You received a letter from the insurance carrier.


Whenever a client presents in my office for a consultation, the first step is to determine whether the insurance carrier has accepted or denied the injury. Not surprisingly, many clients end up coming to my office after their claim was denied.

The obvious question: Why was my claim denied?

The short answer: Any reason they can find.

Whenever a new claim is reported, the insurance adjuster must investigate your case. During that investigation, the adjuster will undeniably look for “red flags,” or reasons to question the injury. Here is a list of some of the things that may raise concern for an insurance adjuster:

  1. New or recent hire.
  2. Injury is reported while employee is working through a temporary agency.
  3. Delay in reporting injury.
  4. Injury allegedly happens on a Friday but is not reported until the following week.
  5. Injury occurs prior to news of a layoff, strike or plant closure.
  6. Injury reported after employee was fired or laid off.
  7. Employee is disgruntled (i.e., denied vacation, demoted or passed over for a promotion, poor performance review, job dissatisfaction, conflict with co-worker(s)).
  8. Recent discipline or termination imminent.
  9. Spike in absenteeism.
  10. Injury coincides with change in personal circumstances (i.e., illness of spouse, pregnancy of employee/spouse, end of seasonal work or project, spouse relocation, separation/divorce, childcare issues, enrollment in college).
  11. Injury reported before planned retirement or vacation.
  12. Employee regularly uses FMLA leave or has a history of STD or LTD claims.
  13. Employee has a history of work-related and/or personal injury claims.
  14. Employee is self-employed on the side with no workers’ comp coverage.
  15. Rumors that accident outside of work.
  16. Employee account of accident/injury does not make sense or has varied.
  17. Security cameras do not corroborate accident/injury.
  18. Body part(s) allegedly hurt changes.
  19. Incident is unwitnessed or witnessed only by friend or relative.
  20. Witness statements are contrary to employee account.
  21. Employee is uncooperative with investigation (i.e., refuses to sign Medical Authorization or limits to post-injury records, refuses to provide Statement, does not return calls).
  22. Refuses offers of modified work.
  23. Insists treating with “own doctor” instead of panel provider.
  24. Shows up at work utilizing “props” when not prescribed (i.e., back/neck/knee brace, arm sling, crutches/cane).
  25. Quickly hires attorney and asks about settlement.

The above list may provide the adjuster with a reason to question the validity of your claim, but it does not provide a legal basis to deny your claim.

If your claim has been denied, you will need an attorney to fight for your right to wage loss and medical benefits. At Gross Law Office, we specialize in workers’ compensation matters. Call today to schedule a free consultation.