Reporting Carrier/Employer Fraud

[1171]

In another post capricorn brought up the issue of claim denial by the employer.

I explained that for the most part an employer does not have the power or authority to deny a claim. The Insurance policy makes it clear that the carrier has the control over claims including which ones are accepted and which are not.
Not only that but many states have strong anti-Fraud laws that not only target workers and other vendors that do business in the workers comp system but anyone including employers or carriers that knowingly deny or reject legitimate claims.
Fraud reporting like workers comp varies among states but generally your local district attorney and/or you state department of insurance handles fraud investigations involving employers and carriers.
Contact them about making a fraud report involving falsifying information that was used to deny or delay the acceptance of an otherwise legitimate claim.

i can give links to some states fraud units.

[tweety00]

ok then 1171 can the employer deny an mri if doctor states in report that it is needed???

would love some sites please!! thank you !

[Tuffy]

Here in Illinois my employer delayed filing my claim,   My attorney filed it for me after my FMLA was up and I was terminated,   Then it took another 3 months before it was accepted,     Would this be considered fraud on my employers part?

I had asked my employer HR several times if my claim was filed and they told me they were taking care of it.

I did receive benefits from my short term disabilite ( 75% of my wages ) and had to use up my vacation time.

[Bad Boy Bad Boy]

Tuffy, here in Illinois, you can report it to both the WC Board, and the Insurance Board.

http://www.idfpr.com/DOI/default2.asp

http://www.idfpr.com/DOI/General/WorkCom...ckList.asp

http://www.idfpr.com/DOI/Complaints/Complaints.asp

[1171]

tweety:

denial of MRI is not considered rejection of a claim.
If you have evidence the MRI denial was done fraudulently contact your local district attorney or the dept of Insurance.
http://www.iid.state.ia.us/complaints/index.asp

[annoyedtodeath]

I would like to know why then, when I contacted the Division of Insurance here in MO. about my Company and their Insurance Company denying me medical benefits, out right lying to me on several issues, and just plain giving me the runaround, why they wrote me back and said that I had to contact the wc people in Jefferson City to deal with it, as they had no control over anything involving work comp?

Just wondering as everything else I have read or heard, they are supposed to help.

Thanks.

[capricorn]

1171.......In my case all evidence is in the Judges hands at this point. Hoping for a decision soon. A representative from the IC called me at 3:00 p.m on the 19th day after injury. (PA you know they have 21 days to accept or deny) I was asked if I was working and said no. She then asked if i had an out of work note from a panel Dr. I assured her I did that my attorney's office sent everything to employer and carrier. Since I had worked with this particular person before and always found her to be helpful through 4 prior injuries I told her I was surprised she called knowing I had an attorney. She said she didn't know that. Told me she was going to call employer and treating Dr. and have the note faxed to her. Keep in mind I have copies of 3 out of work notes from panel Dr.s dated within the 21 days. I figured somehow the carrier never got them. The next morning at 9:00 my mail was delivered with a "Notice of Denial".  I feel she never called anyone to seek these notes and have been told she didn't have to. Also I feel the "notice of Denial" was already done for there is no way I would have gotten it between late afternoon and early morning. It was not sent by overnight mail or certified. I received the certtified copy the following week. Someone messed up here. I have reamed my attorney's paralegal because I believe she may have messed up in sending the notes in a timely fashion. So I can assume that my superviosr made up some story to the carrier since he was pissed at me and they denied it on his word. I also feel had I faxed the notes myself to emplyer and carrier my claim would not have been denied. Make sense?

CAP

[Guest]

1171- Thank you for starting this thread. Some very helpful information here. Question for you.

Would this be considered fraud on the employers/ic side. My injury was caught on video, also I have 4 witness statements saying they were there when I got hurt and saw the entire thing. But yet the claim was denied. Reason being, its not in my job description. I was helping a customer, and customer service is number 1 on the list of my responsibilities and I even have that list in writing. Thankfully, I have my own insurance, so Ive been able to get treatment. However, I have NO income, they owe me back pay from January on. Ive developed depression from this. Youve seen how bad I got a few months back.

Thank you, any information would be helpful!

[Still in Limbo]

Cap, as you know I'm from Pa. also, and I think what happened to you is a total shame!! You should win this hands down, as the Employer has to file your claim within 7 days, and any info. sent them by any board Dr. MUST be forwarded in a timely manner!! I also believe, check with your Attorney, if this case is in your favor and you win which as I said should be a slam-dunk, you may actually have a Civil Suit against your Employer for the suffering you've had to face financially due to pure negligence!! I am going to put every ounce of energy in my prayers that you win this thing, and you get to slap them twice with a Civil Suit also!! Man, just reading what happened to you has my Blood Pressure at 200/200!!

[capricorn]

Oh Limbo ...please don't let me be the cause of your BP going straight up to the sky!!! The only reason I din't give up on this last Nov was because of the circumstances. It is so cut and dry. I have all my ducks in one basket, they have no ducks at all. And to think this all happended to me because my boss was mad at me. Limbo ...When the Judge decides in my behaf IF there is any way I can slap a civil suit on the employer I will just for principal . You don't treat your dedicated employees like this. We have butted heads more times than I can count. There was no reason for this. I was his top manager. Who cares if you like me or not. You don't put a human being through this because you're a cry baby when confronted with issues. OMG , let me stop or I'll really get PO'D. Keep those prayers coming .God bless you for caring.

CAP