Fighting Fraud With Facts

An FHM Specialty

At FHM, we don’t always take a disability claim at face value. As one property manager recently discovered, it takes more than a doctor’s opinion to cash in on a less-than-honest claim for workers’ compensation disability.

The property manager fractured her left shoulder during a slip-and-fall incident at work. Her injury was addressed quickly and generously, including extensive treatment by an orthopedist and two separate surgeries. Two other specialists also got involved in her treatment, yet the claimant continued to complain of pain and immobility. Finally, her treating orthopedist determined that the woman had reached maximum medical improvement, and it was unlikely she would be able to return to work.

The employee sought a $235,000 settlement and remained off work on prolonged disability, claiming inability to work. Based on medical and case information, the FHM adjuster was ready to request authority for over $150,000 and accept the claimant as permanently and totally disabled. There was just one more thing to do first – send out a surveillance crew.

As it turned out, the surveillance team captured video of the woman driving, carrying a purse on her left shoulder, carrying shopping bags and enjoying a manicure. When the treating orthopedist was presented with the video and compared it with the dates of the claimant’s office visits, he changed his opinion, saying the woman had misrepresented herself and was exaggerating her condition. His medical opinion: the claimant could return to work as a property manager.

FHM’s aggressive casework resulted in a settlement of $62,600 – a savings of nearly $100,000 – and kept the policyholder’s liability and coverage costs down. Fighting fraud – just another example of FHM’s policy to do more.

A Policy to Control Fraud – Case by Case

  • Aggressive examination of potentially fraudulent claims
  • Delivering savings of nearly $100,000
  • Prudent usage of surveillance as evidence
  • Reducing overall claims costs for policyholders

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