Begin by looking at everyone else who touches claims, says Laura Clifford, owner of California-based Employers Fraud Task Force.

In a recent interview, Clifford said less than 10% of the comp fraud her firm’s uncovered was committed by employees.

The other 90% was committed by everyone else (lawyers, adjusters, bill review companies, etc.).

First step to take

What can employers do? One tactic Clifford says cuts down on fraud: Sit down with workers with an explanation of the benefits (EOB) they’ve received and go over it with them.

Reason: If just one injured worker looked at his EOB and said, “I only went to the doctor twice, not five times — like it says here,” then the employer could look at that doctor and see what other patients the doc has seen.

What happened

The Equal Employment Opportunity Commission (EEOC) went after Sears, Roebuck & Co., when the company terminated 235 former workers immediately following their return to work after being out on workers’ compensation leave.

Sears violated the ADA when it refused to provide reasonable accommodations to employees who were returning from workers’ comp leave, the EEOC said.

Result: Sears agreed to settle for $6.2 million, and each employee in the suit will receive around $26,300. That’s the largest total settlement in the history of the EEOC.

In addition, Sears improved its workers’ compensation leave process and posted notices regarding the decree, according to EEOC officials.

Do you think this settlement is fair? Let us know in the Comments Box below.

It all depends on the circumstances under which you’re living there.

What happened

A migrant worker broke his angle after falling on a sidewalk where water was flowing from a sink in front of company-provided housing.

The South Carolina Workers’ Comp Commission said that because he wasn’t required to live in the housing, he shouldn’t get comp.

But the man appealed to the State Supreme Court, which overturned the decision.

Why? The court found the man was essentially required to live in company-provided housing because he wasn’t paid enough to be able to rent seasonal housing.

Tell us whether you agree with this decision in the Comments Box below.

Cite: Pierre v. Seaside Farms, Inc.

Well, the courts do. And that’s good news for employers looking to keep insurance premiums down.

That exact situation caused a court in Illinois to deny a claim for workers’ comp benefits.

What happened

A man claimed he was injured three different times (on three separate occasions) at work. However, he reported the injuries 15 weeks after the first alleged incident, seven weeks after the second and a week after the third.

Two other problems:

• Throughout those 15 weeks the worker saw his primary care doctor and chiropractor several times — and never mentioned anything about a work injury, and
• His manager said he couldn’t link his medical condition to a specific work incident when he finally did report the injury.

Case closed: The man’s request for workers’ comp benefits was denied.

Have you every come across a situation like this? Tell us about it in the Comments Box below.

Cite: Hosteny v. IL Workers’ Compensation Commission

What happened

Jesse Cooper, a master plumber and foreman, was on location to discuss the details of a job with a customer.

But when he arrived at the customer’s facility, he found the person he needed to talk to wouldn’t be available for 45 minutes. So Cooper decided to get a cup of coffee at a local deli.

On his way there, Cooper was involved in a car accident that broke one of his arms and both of his legs.

He was granted disability, but his employer appealed, arguing the accident happened on an errand that wasn’t work related.

The court’s decision

A judge upheld the comp award. The judge said injuries that occur during “minor deviations” from employment are covered by workers’ comp if the employee works off site and doesn’t report to the same facility every day.

Do you agree with the judge’s decision? Let us know in the Comments Box below.

Cite: Cooper v. Barnickel Enterprises

What happened:

While lifting boxes at work, a man suffered a back injury which required surgery. During his recovery, he was unable to work and received workers’ comp benefits.

The employee said that pain in his leg, which was a result of the back injury, forced him to walk with a limp and limited his activities. He claimed he could only “lift a little.”

But he was caught on tape picking up and swinging his grandchildren.

In addition, when the insurance carrier’s doctor saw him, he walked with a severe limp. But when the doctor watched him walk out to the parking lot, the limp had noticeably improved.

Benefits cut off — permanently

The Workers’ Compensation Board in New York State ruled to cut off his benefits. It also ruled to disqualify him from receiving any workers’ comp in the future.

The worker appealed the decision in a state court, but the decision was upheld.

Did the worker get what he deserved, or was the court’s ruling too harsh?

Cite: Church v. Arrow Electric (PDF)

What happened

A female worker was injured while traveling to a shopping center to buy food and gifts for a holiday party at her employer’s office.

Her husband was driving her to the shopping center when he lost control of his truck. It struck a median and rolled over several times.

The worker then applied for workers’ comp. Did she get it?

The decision

Yes. A workers’ comp judge concluded she should collect comp benefits because she was injured while performing a work-related duty that benefited her employer.

The judge’s reasoning: Her employer supported holiday parties as a way to build teamwork. Plus, the worker was on call at the time of the crash.

Her employer appealed the comp award to a workers’ comp board, a state appeals court and finally the state supreme court. At every step, the decision was upheld.

Cite: Casarez v. Davita, Inc.

Coming across a public confession on the Internet.

Several companies have recently used info found on sites like Facebook, MySpace and LinkedIn to fight fraudulent workers’ compensation claims.

Sometimes, employees will blatantly brag about fooling companies. More often, though, they’ll describe strenuous activities they’ve recently participated in (playing sports, for example) while they’re supposedly too injured to work. For example:

• A Los Angeles-area warehouse worker filed a work-related back injury claim — but then posted on Facebook about bowling tournaments he’d competed in, after the injury.
• Dollar Tree had paid out over $100,000 over a year and a half to an employee with back problems. Her MySpace page listed a side job as a wedding photographer. Suspicious, the company sent representatives to conduct surveillance, and the employee was spotted lugging heavy camera equipment with no signs of back pain.
• Claims investigation service GlobalOptions Group even reports finding an employee who posted videos of himself competing in a rodeo while he was supposedly too injured to get out of bed.

Yes — if the employer sponsors the activity, said a New York appellate court in a recent workers’ comp case.

What happened

Frank Torre worked for Logic Technology, a company that performed on-site contracting work for General Electric.

Torre suffered a spinal cord injury while participating in an exercise class at the General Electric fitness center during work hours. He claimed workers’ comp should pay for it.

The court agreed. Although it found that Torre’s employer didn’t require him to participate or compensate him for taking the class, it did pay a portion of his membership fee.

Also, Torre’s job required him to develop contacts with current and prospective clients. And Logic Technology’s president stated that participating in the class would help him develop those contacts.

Result: The court ruled that his injury arose out of, and in the course of, his employment.

What the law says

New York follows this general rule: Employees cannot collect workers’ comp benefits for injuries that result from their “voluntary participation in an off-duty athletic activity not constituting part of the employee’s work-related duties.”

However, there are exceptions to this rule — like if the employer sponsors the activity or requires workers to participate in it.

While this particular ruling only applies in New York, it’s something other employers should keep in mind when designing wellness programs.

Cite: Torre v. Logic Technology.

The social networking site was recently in the middle of a workers’ comp dispute. Here’s what happened:

An employee of Virginia-based airline Colgan Air filed for disability benefits after she was injured on the job. The company initially paid the benefits but became suspicious after the employee wouldn’t cooperate with efforts to find her a job she could do.

Colgan appealed the case, suspecting that photos from the employee’s recent vacation would prove the injury wasn’t as serious as she claimed. So the company looked in the place where people most often store photos and other personal information: Facebook.

The employee’s profile had been marked as private, but the court agreed the evidence would be helpful and sent a subpoena asking Facebook to hand over “all documents, electronic or otherwise, related directly or indirectly, to all activities, writings, photos, comments, e-mails, and/or postings” in the employee’s account. A $200-a-day fine for noncompliance was threatened.

Facebook refused on privacy grounds. The court eventually backed down.

The company in this case failed to round up the evidence it needed — but many other employers have successfully fought comp and other claims by using information freely made public on social networking sites.