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Workers' compensation fraud is a felony.
NYSIF investigates workers' compensation fraud only for NYSIF policies and claims. If you have information regarding any type of fraud against NYSIF, NYSIF makes it easy for you to report fraud.
Because of the complexity of cases and tremendous losses associated with workers' compensation fraud, insurers have combated it by creating special investigation units to pursue fraud criminals. By industry estimates, each dollar spent on special units to fight fraud returns $7 to $10 in savings through deterrence or restitution.
NYSIF's special investigation unit, the Division of Confidential Investigations (DCI), has established itself as a local and national leader in arrests and prosecutions of felony fraud cases against policyholders, claimants and medical providers.
NYSIF continually educates its staff and businesses in New York to recognize potential fraud cases.
Be aware of the mechanisms of fraud used by the claimant or medical provider, including:
As an industry leader in the fight against workers’ compensation fraud, NYSIF encourages policyholders to be aware of common red flags that my signal potential claimant fraud. Red flags are not of equal importance or weight, nor do they, in and of themselves, prove anything. As a general rule, if you find clusters of red flags connected with a claim, the claim should be examined with care to determine if the claimant has lied about any material fact connected with the claim.
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Injury reported after a serious problem on the job, such as disciplinary action, demotion, being passed over for a promotion, or notified of a layoff. Worker is a new hire, or has a prior history of multiple personal injury or workers’ compensation claims.
Injury reported soon after purchase of private disability insurance. Worker engages in high-risk leisure activities. Worker experiencing financial difficulties or domestic problems at time of injury.
Accident occurs early Monday or on the day of return from vacation, or was not immediately reported. Worker’s description of accident has inconsistencies or is not believable. Accident is not witnessed, or witnesses’ descriptions contradict injured worker’s account. Injury is inconsistent with activity at the time of injury.
Claimant difficult to contact during working hours, uses an answering machine to screen calls, or a post office box as a residential address.
The primary mission of NYSIF’s Division of Confidential Investigations (DCI) is to investigate cases of suspected fraud, including policyholder, provider and claimant fraud, against NYSIF and to refer completed investigations for criminal prosecution.
Report workers’ compensation fraud