Workcover Investigations by CCS

CCS have over 40 years of experience investigating fraudulent Workcover claims across Australia.

Complete Corporate Services (CCS) have conducted thousands of Workcover investigations, developing a large skill base and experience in this area, including specialist factual, intelligence and surveillance skills.

Many workers necessarily are forced onto Workcover payments after they are injured during the course of their work, and or during journeys to and from work.  The Workcover mandatory insurance scheme protects workers from losing income whilst they recuperate and are fit for work again.

All claims are carefully assessed by claims managers as to their validity.  In some instances, investigators are appointed either by Workcover itself or by Employers to investigate the validity of claims or extent of injury.

What is Workcover?

WorkCover is a government owned statutory body, providing workers’ compensation insurance to employers. It is mandatory for all employers to hold a workers’ compensation accident insurance policy. If you are an employee, you are covered by your employers’ workers’ compensation insurance policy.

Each state and territory governs their own workers compensations such as ACT, NSW, NT, QLD, SA, TAS, VIC and WA.

What is Workcover Fraud?

WorkCover Fraud occurs when a worker dishonestly reports an injury and claims a range of entitlements that the worker is not legally entitled to.

Some Examples of Workcover Fraud

Unfortunately, a small number of employees take advantage of the Workcover insurance scheme by making claims for injury that are not legitimate.  Some examples include:

A claim for an injury which occurred outside of work and is non-work related. 

 

This could be an injury that occurred during exercise or other activity during private time and not related to work.Of concern is the increase in the number of work-related psychological injury claims that are not work related by have been sustained as a result of events in a worker’s private life.For example, a marriage breakdown, poor finances, and or drug and alcohol abuse.

 

A pre-existing injury or degenerative injury non-related to work. 

 

In jobs that involve manual labor, for example concreating, bricklaying, and tiling it is common for workers to carry old work or non-work-related injury or degenerative illnesses.Such injury may make it difficult for the worker to perform his or her duties and subsequently they unlawfully claim that these injuries have occurred during their current working environments.

 

A claim for an injury that does not exist and or never occurred. In some instances, workers will claim for an injury that never actually occurred. 

 

Examples can be a sore back or neck with a representation that these injuries occurred during work activity, when they did not.There has been a growth in psychological injury claims that are without foundation.

 

Remaining on Workcover insurance payments and remaining away from work, after the injury has healed and the claimant is capable of returning to work.  

 

Probably one of the largest areas of Workcover fraud occurs when workers extend the time that they are on Workcover and are paid benefits when they are fit to return to work.The worker will convince medical practitioners that they are still carrying an injury, are not fit for work and continue to avoid work, whilst on full pay.In some instances, workers have managed to stay on Workcover leave for years longer than required, until exposed through investigation.The instance of this type of fraud is prevalent in psychological injury claims.

 

Provision of a fraudulent medical certificate to illegally obtain Workcover.

A large area of Workcover fraud occurs when either a worker forges and produces a medical certificate that is in fact false, or alternatively obtains a certificate from a medical practitioner who is prepared to support a claim by the worker, without real medical evidence of injury.This certificate is then relied upon by Workcover to continue to provide benefits to the worker, who is not entitled to such.

 

Performing other work outside of employment whilst on Workcover insurance payments.

 

A number of employers will hear on the grape vines that an injured worker is performing work whilst on sick leave.Often those employers will want investigation undertaken into this.This is often common amongst trades persons, who have the ability to gain referral work through their own networks or social media.

 

A worker is incapable of a certain type of work, but can actually do that type of work outside of work hours.

 

This is common. An example may be an injured mechanic on Workcover leave is serving vehicles for payment in his home garage.

How are Workcover investigations conducted?

Private investigators (PIs) are used to carry out WorkCover investigations. Investigations are one of the tools that may be used in the claims management process.

 

They assist to:

  • assess liability

  • determine common law entitlement

  • determine entitlement in other litigated matters

  • establish whether there has been scheme abuse.

 

WorkCover authorises a number of investigator providers as the only firms who can carry out WorkCover investigations.  

Employers must not exert influence in the claim’s investigation process.

Employers are entitled to instruct their own investigators.

PI code of practice

Registered PIs must comply with WorkCover's Code of Practice for Private Investigators as a condition of their registration.The Code introduces a common set of high conduct and quality standards that have to be accepted and adhered to by any existing or new registered investigator before they are eligible to be allocated WorkCover work.

PI responsibilities

  • The responsibility for the proper conduct and control of the circumstance investigation remains with the investigator.

  • The investigator is expected to display attentiveness, compassion and an appropriate level of care when conducting a circumstance investigation.

  • The investigator allocated to the case should have a minimum of 5 years relevant experience in conducting investigations.

Arrange interview

  • The claimant should be given the option of being interviewed by an investigator of the same sex.

  • The investigator must ensure the claimant is advised of their right to have an independent representative or support person present at the time of interview and actively encouraged to exercise this right. If a claimant requests or nominates an independent person or support person to be present during the interview, the investigator must not start the interview until that person is present.

 

Prepare for interview

  • The investigator should prepare relevant information before starting the interview in order to minimise the time required for the interview.

  • After the investigator has clearance to contact the claimant, they should, when arranging the appointment, tactfully and carefully tell the claimant what to expect during the interview. Appointments should be confirmed in writing.

Conduct interview

  • Upon arrival at the agreed location for the interview, the investigator must consider the demeanour of the claimant and based on their own skills and experience, determine if it is appropriate to start the interview at that time.

  • At the start of the interview, the investigator must clearly outline the claimant’s rights and advise of the following:

  • The right to terminate or reschedule the interview at any time.

  • The right to suspend the interview to have a break at any time.

  • The right not to answer a question that is put to them.

  • That the investigator is not responsible for making determinations related to their claim for compensation benefits.

  • That the investigator has a responsibility to ask a wide range of questions in order to enable the decision maker to assess their claim.

  • The investigator must be vigilant at all times during the interview to any change in the claimant’s demeanour and be alert to any signs of fatigue.

  • The investigator must take control and terminate the interview if they consider it in the best interest of the claimant, notwithstanding that the claimant may wish to continue.

  • The investigator must make all efforts to limit the length of the interview to four hours, unless the interviewer reasonably believes that the interview is close to completion and the claimant agrees to continue.

  • The investigator should ensure that questions are confined to issues relevant to the claim.

 

Circumstance (factual) investigations

WorkCover and Employers request circumstance investigations to determine the facts surrounding an injury for which a workers' compensation claim has been made. These investigations are also referred to as ‘factual investigations.

Circumstance or factual investigations are often arranged to:

  • assist in the determination of liability

  • examine common law potential

  • examine recovery potential

  • investigate other aspects of the claim.

Liability

Factual investigations assist in the determination of liability and contribution.

Common law

The report could include the following:

  • analysing the alleged accident circumstances

  • obtaining relevant evidence, including (but not limited to):

  • witness statements

  • video of workplace and or work practices

  • photographs

  • obtaining employment documents about the worker, including (but not limited to):

  • the application for employment

  • wage and leave records

  • medical certificates of any nature

  • the accident injury report book

  • any safety investigation reports relevant to the alleged incident/s

  • group certificates for three financial years before the incident/s.

 

Surveillance (activity) investigations

Surveillance investigations are a claims management tool used by Agents to discreetly determine a worker's activities and capabilities.  

Surveillance should only be used if:

  • other less intrusive methods of investigation have been considered and have been assessed to be ineffective and inadequate or have been tried and found to be inconclusive and

  • there is adequate evidence to suggest the worker may be:

  • misrepresenting their disability

  • claiming excessive disabilities or

  • involved in the commission of a fraud.

Information privacy

In performing surveillance activities, Private Investigators are bound by the Information Privacy Principles set out in the Information Privacy Act 2000.

Complete Corporate Services provide private investigation services across Australia, including Sydney, Gold Coast, Brisbane, Sunshine Coast, Cairns, Ipswich and Mackay.

We encourage clients to call and discuss their consumer fraud needs to see whether we can assist.

Call 1300 911 334 to discuss your needs, on a strictly confidential, no obligation basis

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