Employee Misrepresentation in Workers’ Compensation Claims

Questions could arise during a workers’ compensation claim investigation if certain circumstances suggest the reported incident may not have occurred at work or in connection with employment.

Knowing how inconsistencies related to these five types of employee misrepresentation may appear can help adjusters decide whether additional fact gathering from a licensed investigator is appropriate.

Select a chapter below to begin reviewing types of potential employee workers' compensation misrepresentation, learning about the workers' comp industry, testing your workers' comp claims knowledge, and exploring adjuster-focused resources.

For the best experience, view this guide on a desktop computer.

Scroll to review types of potential employee workers' compensation misrepresentation, learn about the workers' comp industry, test your workers' comp claims knowledge, and explore adjuster-focused resources.

For the best experience, view this guide on a desktop computer.

Chapter 1: Types of Workers' Comp Misrepresentation

Chapter 2: By the Numbers: Work-Related Injuries

Chapter 3: Test Your Workers' Comp Claim Investigation Knowledge

Chapter 4: Explore More Adjuster-Related Resources

Chapter 5: Submit an Assignment

Chapter 1

Types of Workers' Comp Misrepresentation

Swipe through the slideshow to learn about common types of employee misrepresentation that may appear in workers' compensation claims.

Malingering

Malingering may involve the intentional exaggeration or prolonging of reported symptoms or limitations associated with an injury. Because recovery periods vary based on the injury and individual circumstances, potential inconsistencies should be evaluated in context rather than based on recovery time alone.

Red Flags

Unexplained refusal or repeated avoidance of recommended diagnostic procedures when inconsistent with the reported severity of the condition
Inconsistent descriptions of what caused the reported injury
Reported limitations involving conditions that may be more difficult to objectively measure, when combined with other inconsistencies in the claim
Publicly available social media activity that appears inconsistent with claimed limitations

Working While Collecting

Working while collecting may involve undisclosed employment or income that is inconsistent with reported work restrictions or benefit eligibility. Outside employment itself does not establish misrepresentation; the relevant issue is whether the activity was required to be disclosed or conflicts with reported limitations.

Red Flags

Unexplained income or employment that may be relevant to benefit eligibility
Consistent unavailability during expected contact periods without explanation
Calls consistently returned only during evenings or weekends, when combined with other relevant information
Observed activity or travel patterns during work hours that are inconsistent with reported restrictions or stated availability

Non-Work Injuries

Non-work injuries may involve a legitimate injury that occurred away from work or outside working hours but is reported as having occurred in connection with employment. Investigation may be appropriate when available facts raise questions about where, when, or how the injury occurred.

Red Flags

Lack of witnesses when other circumstances surrounding the reported event are inconsistent or unclear
A reporting delay that is unexplained or inconsistent with the reported circumstances
A claim reported after termination or another significant employment event, when accompanied by other factual inconsistencies
Evidence of recent recreational or non-work activity that may be relevant to the reported mechanism or timing of injury

Fabricated Injuries

Fabricated injuries may involve a reported injury that did not occur as described and may be accompanied by altered, inconsistent, or unsupported documentation.

Red Flags

Vague or materially inconsistent details regarding the reported incident
A reported incident location that is inconsistent with other known information
Witness accounts that materially conflict with the claimant’s version of events
Video, surveillance, or other evidence that appears inconsistent with material claim details

Undisclosed Prior Claims or Injuries

Prior claims or injuries may become relevant when they involve the same body part, similar symptoms, overlapping periods of disability, or facts that are inconsistent with information provided in the current claim. The existence of prior claims alone does not indicate wrongdoing.

Red Flags

Prior claims involving the same body part or similar reported mechanism that were not disclosed when relevant
Material inconsistencies between current claim statements and documented prior claims or injuries
Overlapping periods of disability, treatment, or claimed limitations that warrant clarification

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Chapter 2

By the Numbers: Work-Related Injuries & Employee Workers’ Compensation

Understanding the volume and potential financial impact of workers’ compensation misrepresentation gives insurance professionals additional context for why objective fact gathering can play an important role when claim inconsistencies arise.

Hover over each image below for insights into the workers' compensation industry and related claims.

of claimants' flagged online content connected them to a business other than their main employer, according to a Carpe Diem review of 2024 open injury claims.

is the estimated amount that workers' compensation fraud costs annually, while employer fraud is estimated to cost $25 billion annually.

private-industry sectors with the most nonfatal occupational injuries & illnesses in 2024 included trade, transportation, & utilities; educational & health services; & manufacturing.

workers’ compensation claims were filed with the U.S. Department of Labor, and more than $16.5 billion had been paid as of October 2026.

Chapter 3

Test Your Workers' Comp Claim Investigation Knowledge

Take this brief true or false quiz to see how well you know workers' compensation claim investigation principles.

QUESTION 1

A single red flag in a workers’ compensation claim guarantees wrongdoing.

CORRECT!

One questionable element in a claim does not mean fraud has occurred. However, it is still worth looking into further to ensure determinations are made based on all available facts.

INCORRECT!

One questionable element in a claim does not mean fraud has occurred. However, it is still worth looking into further to ensure determinations are made based on all available facts.

QUESTION 2

Red flags may justify additional fact gathering, but they are not proof of wrongdoing.

CORRECT!

Suspicious or unanswered questions do not prove fraud. They do, however, suggest that further inquiry may be necessary to help provide adjusters with all the necessary details to resolve claims.

INCORRECT!

Suspicious or unanswered questions do not prove fraud. They do, however, suggest that further inquiry may be necessary to help provide adjusters with all the necessary details to resolve claims.

QUESTION 3

Investigations are intended to document facts & provide information for adjusters rather than determine if fraud occurred.

CORRECT!

Investigators do not tell adjusters if fraud occurred. They document objective facts and compile them in an unbiased report that the adjuster will use to make an independent determination.

INCORRECT!

Investigators do not tell adjusters if fraud occurred. They document objective facts and compile them in an unbiased report that the adjuster will use to make an independent determination.

QUESTION 4

Adjusters often have enough initial claim information for an investigator to begin developing an investigative strategy.

CORRECT!

Basic facts, such as the claimant's name and the incident details, can be a good starting point for investigators to begin determining the best fact-gathering approach for each unique assignment.

INCORRECT!

Basic facts, such as the claimant's name and the incident details, can be a good starting point for investigators to begin determining the best fact-gathering approach for each unique assignment.

Chapter 4

Explore More Adjuster-Related Resources

Read and save these adjuster-focused materials, which can help you with your workers' compensation claim determinations.

Workers’ Compensation Claim Investigations eBook

Read this eBook to learn about workers’ compensation claim misrepresentation and how investigative partners help adjusters verify facts when questions arise.

Download the eBook

Workers’ Compensation Claim Investigation Case Study

Learn how an adjuster identified inconsistencies in a workers’ comp claim involving a reported fall and what an investigator identified in social media activity.

Access the Case Study

Common Employee Workers’ Compensation Fraud Schemes

Discover common types of employee workers’ compensation misrepresentation and how expert investigations can help validate claim facts.

Read the Article

Chapter 5

Submit an Assignment

Let our licensed investigators document the facts so you can make claim determinations with confidence.

VRC Investigations provides a variety of professional investigative services, including surveillance, social media investigations, canvassing, claims investigations, regulatory compliance guidance, and litigation support. Our team of skilled investigators is positioned in strategic locations throughout all 50 states. Contact us at the link below.

Submit an Assignment

VRC Investigations, part of the Alpine Intel suite of services, is a national provider and single-source solution for investigative, SIU, and regulatory compliance needs. Dedicated to integrity and collaboration, our team of skilled investigators delivers comprehensive reports that document claim facts, address potential inconsistencies or misrepresentation, and enable clients to make confident and timely decisions across workers’ compensation, auto, and other claims.