Claim Study: Ingenious Strategy


by: Alan Daigrepont, Senior Claims Consultant

Ingenious Strategy

Several newsletters ago, we reviewed the importance of investigation and utilizing social media to thwart bogus claims. Our injured worker thought she had outsmarted the system.

The claim began innocently enough with a strain/sprain injury to the lower back. The initial red flag was the choice of physician the injured worker demanded. Efforts to divert her to a physician less liberal were unsuccessful. Knowing the reputation of the medical provider, a Second Medical Opinion (SMO) was secured quickly, then followed by a state Independent Medical Exam (IME).

The opinions of the SMO and IME were favorable and confirmed the injured worker was not a surgical candidate. With this documentation, one would suspect the injured worker’s physician would consider alternative forms of treatment, but each month, the medical reports read the same: “no work status” / four different medications and “return to clinic in four (4) weeks”, became routine.

Little did the injured worker realize that surveillance had been conducted several times, and searches completed on the claimant’s social media account. Still, there was not any confirmed information to prove to a judge that the claim was “fraudulent” but information continued to be collected.

The offer of Private Mediation to resolve the claim was suggested to the injured worker’s attorney, and accepted. Over many hours, negotiations were less than fruitful. The two parties were many thousands of dollars apart. UNTIL . . . .

The Mediator was shown the evidence derived from social media, compared this to the written documentation in the medical records and attempted to convince the injured worker’s attorney of the potential of statute violations. We requested the evidence not be actually revealed to opposing side, in the event negotiations broke down and litigation be filed.

Still miles apart, the injured worker made a final demand and indicated this to be the “rock bottom” demand. She was convinced there was nothing on her social media postings to indicate anything of use during a potential trial. She was mistaken!

The day following the unsuccessful mediation, the claim was immediately suspended and was rapidly followed by a Disputed Claim for Benefits (ie: lawsuit). The assignment of defense was made with the following instructions to the defense counsel: (1) Answer the petition with a general denial; (2) Immediately request the deposition of the claimant; AND (3) Immediately set the deposition of the injured worker’s twin sister and their close friend. You see, injured worker hadn’t realized one could access “friends” postings and these revealed more evidence than she’d thought.

Once the outside parties were mentioned and potentially to be held accountable to her story, the attorney for the injured worker called and immediately accepted our last offer, which was some $20,000 less than their “rock bottom value.”

When attempting to negotiate a claim to resolution, it is often wise to withhold some information, in the event legal discovery is required. The injured worker felt strongly there was nothing revealed on her social media account to incriminate her (her bluff), yet through the use of the concrete medical records/surveillance and ingenious strategy, an amicable resolution was obtained for a very frustrating claim.

If you have any questions related to this blog post, please contact:

Alan Daigrepont

Senior Claims Consultant

Senior Risk Consultant

Senior Risk Consultant