ACM’s claims examiner was assigned a two-month late report: a post-termination work injury claim. The attorney reported that the claimant fell from scaffolding, two stories off the ground, suffering major injuries. The insured said the claimant did not work on the claimed date of loss, nor did any of their staff, as they are closed on Saturdays. In fact, he had walked off the job a week earlier. The claim was referred to the SIU.
The investigation verified that the claimant had already walked off the job mid-shift, a week before the claimed date of injury. When he picked up his final check the following Friday, he signed a form verifying that he had not been injured at work. The investigation showed that the claimant went to the hospital on the following day, claiming he fell while working that day. The claim was denied.
Medical records were ordered. The claimant’s QME evaluation was scheduled. The Applicant Attorney then dropped the case, and the claimant failed to show for the QME.
The WCAB dismissed the claim with Prejudice.
Late report/post-termination claims are always worthy of a closer look. This is especially true right now in the construction, home care and delivery trades, where there is an abundance of cash labor. Thanks to the claims examiner’s and our efforts, the claim was denied, and the employer’s x-mod didn’t take the hit of another CA false claim.