Compensability Investigation

Investigations are the means of obtaining factual information regarding the details of a claim by reconstructing and preserving detailed information from the various parties involved in an incident. The investigation is used in the analysis of the claim and provides a basis for the determination of the disposition of a claim.

Agencies should first determine what their plan of action will be when/if an incident occurs. Pre-accident planning is essential when developing policies and procedures for the investigation of incidents. Procedures are necessary for answering alarm systems, notification of incident, what incident report forms you will need, what personal protective equipment (PPE) is available, where to keep the investigator's kit, how to initiate a rescue attempt/first aid should be developed. You will need to determine who will investigate and what training is needed. Securing the scene is an important function and should be done not only because of possible evidence that needs to be collected but for safety reasons as well. Most supervisors should be trained and equipped with the necessary tools since they are usually one of the first on the scene.

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The statements can be obtained from the injured party, the employer, eyewitnesses, responsible parties, and other people (i.e.: emergency services personnel) who may have pertinent information regarding the claim. A good preliminary investigation that includes statements can provide the disability determination examiner the opportunity to limit the injuries that may have resulted from the submitted claim. Witness and injured worker statements are used to pin down the facts regarding a claim. Although it is not the primary purpose of a statement, a statement can also be used to challenge, confront, or censure the statement of a witness who later changes his/her account of the facts surrounding the incident.

The agency's role in an investigation

• Appoint an accident investigator who has received training to conduct all investigations.
• Conduct on-the-scene investigations immediately following the incident in order to record condition, preserve evidence, identify possible witnesses, and get statements while details are still fresh and witnesses have not had time to have discussions and change minds.
• Be open minded. Do not make your own assumptions. Your attitude can sway a witness and make a difference in the outcome of an investigation.
• Obtain background information on injured worker and witness. We need to know if the witnesses are related, friends, or enemies and what type of witnesses will we be dealing with (personalities, character).

Who needs to be interviewed

• Interview all witnesses, co-workers, previous shift workers, and the injured party.

  Interview all witnesses regarding their knowledge about the incident.
• Interview co-workers and previous shift workers.
• Interview the injured party last, after you have obtained all other information from both the scene and witnesses.

What makes a good investigation

• Obtain factual information -- all information collected during an investigation must be verifiable.
• Using your guides, ask open-ended general questions.
• It is important to submit all forms and statements timely to ensure an appropriate determination of compensability has been made on the claim.
• Third-party consideration (subrogation): We may be able to recover the medical and income benefits paid on a claim if we can prove that negligence by a third party was a contributing factor in an incident. It is important to secure items without modification.

What facts do we need and how do we get them

• Pictures of the scene and/or diagrams with placement of witnesses and injured worker.
• Measure distances and weights.
• Collect pertinent information from the agency.
• Take written or recorded statements from witnesses.
• Get a statement (written or recorded) from the injured worker.
• Document investigation.

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Questions that need to be answered during an investigation are: who, what, when, why, where and how. In order to accomplish this, you will need to have the following analysis tools:

1. Camera    

2. Note pad for documenting      

3. Ruler for measurements, diagrams, and comparisons

 
4. Agency and SORM forms
 

5. Tape measure for measurements     

6. Coin for comparisons 

7. Thermometer when temperature is a factor  

8. Caution tape for prevention and security

9. PPE -- personal protective equipment      

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Statements are a form of communication that takes place in the form of questions and answers. The manner in which you ask the questions will have a great impact on the effectiveness of the statement. Obtaining a statement is not just a matter of asking a few questions and waiting for a response. There is actually a great deal of skill necessary in taking a good statement.

Preparation
In order to obtain an effective statement, make sure you understand, as much as possible, everything involved in the case at the time the interview is conducted. Thoroughly review all information available.

Organize your thoughts. What information do you want the statement to include? Identify the issues that need to be addressed during the interview process and have a list of questions ready to be asked regarding each issue. Record the interview.

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The following questions are to be used as a guide in drafting the questions that need to be answered when conducting interviews. Create your list of questions and leave extra space for your notes on information shared during the session that needs to be expanded on or clarified. We have included guides for different situations, different sources, and an example of general introductory questions that need to be answered at the beginning of all interviews.

• Guides
  • Introductory Questions and Information Needed From Agencies, Witnesses, and Injured Workers
  • Exposure
  • Slips, Trips, and Falls
  • Heart Attacks
  • Repetitive Trauma
  • Lifting and/or Back Injuries
  • Travel Injuries

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SORM investigates fraud in the workers' compensation system.

Workers' compensation fraud is committed when a person(s) knowingly or intentionally misrepresents, conceals, or omits a material fact to either obtain or deny workers' compensation benefits.

To prove fraud, there must be documented evidence proving that the person(s) knew their actions were wrong or the representations that they made were false and incorrect. For successful prosecution of a case, one must ask the question, has the person "lied" regarding any issues of the workers' compensation claim? If you cannot prove the lie, then it is not provable fraud.

Knowledge and intent is the most difficult aspect to prove in workers' compensation fraud. Utilizing adjuster notes, recorded/transcribed statements, medical reports, and witness statements are only a few of the ways this can be achieved.

Even though it is preferred, there does not have to be a monetary loss incurred by the carrier to make a case. An attempt to gain payment by a person(s) to obtain or deny workers' compensation benefits is sufficient to prosecute.

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In every case there are circumstances that would lead a person to question the integrity of the claim. That is not to say that fraud is proven, but that, based on the experience of people in the workers' compensation fraud arena for some time, when one or more of these circumstances are seen in a case, there is statistically a greater potential for the case to contain elements of deceit.

• Fraud Indicators
  • Accident Indicators
  • Claimant Indicators
  • Medical Treatment Indicators

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• Call SORM's investigators:
  • Gary Ingram at (512) 936-1450, or
  • Julie Herrera at (512) 936-1521.
• Call your SORM adjuster or our main number at (512) 475-1440.

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Risk-Tex, SORM's external newsletter

• Oct. 2003 -- Investigations vital to state by Sam Arant
• July 2003 -- Why we focus on "cause" by Curt Krill

Incident/Accident Investigation Form, SORM 703, with detailed instructions to assist state agencies in documenting accident investigations