Workcover and Workers Compensation Fraud and Investigations by CCS

Complete Corporate Services (CCS) have conducted thousands of Workcover and workers compensation 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 term used in Australia to refer to a system of laws, policies, and procedures that provide financial and other support to workers who are injured on the job or become ill as a result of their work. WorkCover typically includes provisions for workers' compensation insurance, which provides financial benefits to workers who are unable to work due to a workplace injury or illness. WorkCover may also include provisions for rehabilitation and return to work support, as well as support for workers who are permanently disabled due to a workplace injury or illness. The specific details of WorkCover vary from state to state within Australia.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 the Difference Between Workcover and Workers Compensation?

In Australia, WorkCover and workers' compensation are similar in that they both provide financial and other support to workers who are injured on the job or become ill as a result of their work. However, the specific terms and details of these programs can vary from one jurisdiction to another within Australia.

In general, WorkCover refers to the system of laws, policies, and procedures that provide support to workers who are injured or become ill due to their work, and this system may include provisions for workers' compensation insurance. Workers' compensation, on the other hand, refers specifically to the financial benefits provided to workers who are unable to work due to a workplace injury or illness.

It is important to note that the specific details of WorkCover and workers' compensation programs can vary depending on the state or territory in which a worker is located. It is recommended that workers consult the WorkCover or workers' compensation program in their specific jurisdiction for more information on the specific terms and benefits available to them.

What is Workcover or Workers Compensation Fraud?

WorkCover fraud refers to the act of intentionally providing false or misleading information in order to obtain WorkCover benefits or to avoid paying WorkCover premiums. WorkCover fraud can be committed by workers who claim to have suffered a workplace injury or illness when they have not, or by employers who fail to report workplace injuries or illnesses or who provide false information in order to avoid paying WorkCover premiums. WorkCover fraud is a serious offense and can result in criminal charges and fines, as well as the loss of WorkCover benefits.

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.

What are the difference in laws for Workcover and workers compensation in each state?

In Australia, the laws governing workers' compensation, also known as work cover, vary by state and territory. However, the general principles of the laws are similar.

In general, workers' compensation laws require employers to have insurance to cover the costs of workers who are injured on the job or develop a work-related illness. These laws also provide benefits to workers and their families in the event of a work-related injury or illness, including medical treatment, lost wages, and other types of financial assistance.

Each state and territory in Australia has its own workers' compensation authority, which is responsible for administering the laws and providing assistance to workers and employers. The specific benefits and coverage provided under the laws can vary by state or territory, so it is important to check the laws in your specific location.

Here is a summary of the main points of the workers' compensation laws in each state and territory in Australia:

• New South Wales: The Workers Compensation Act 1987 and the Workers Compensation Regulation 2016 provide the legal framework for workers' compensation in New South Wales. The law requires employers to have insurance to cover the costs of work-related injuries and illnesses, and provides benefits to workers, including medical treatment, lost wages, and other types of financial assistance.
• Victoria: The Workplace Injury Rehabilitation and Compensation Act 2013 and the Workplace Injury Rehabilitation and Compensation Regulations 2016 provide the legal framework for workers' compensation in Victoria. The law requires employers to have insurance to cover the costs of work-related injuries and illnesses, and provides benefits to workers, including medical treatment, lost wages, and other types of financial assistance.
• Queensland: The Workers' Compensation and Rehabilitation Act 2003 and the Workers' Compensation and Rehabilitation Regulation 2014 provide the legal framework for workers' compensation in Queensland. The law requires employers to have insurance to cover the costs of work-related injuries and illnesses, and provides benefits to workers, including medical treatment, lost wages, and other types of financial assistance.
• Western Australia: The Workers' Compensation and Injury Management Act 1981 and the Workers' Compensation and Injury Management Regulations 1982 provide the legal framework for workers' compensation in Western Australia. The law requires employers to have insurance to cover the costs of work-related injuries and illnesses, and provides benefits to workers, including medical treatment, lost wages, and other types of financial assistance.
• South Australia: The Return to Work Act 2014 and the Return to Work Regulations 2015 provide the legal framework for workers' compensation in South Australia. The law requires employers to have insurance to cover the costs of work-related injuries and illnesses, and provides benefits to workers, including medical treatment, lost wages, and other types of financial assistance.
• Tasmania: The Workers Rehabilitation and Compensation Act 1988 and the Workers Rehabilitation and Compensation Regulations 2010 provide the legal framework for workers' compensation in Tasmania. The law requires employers to have insurance to cover the costs of work-related injuries and illnesses, and provides benefits to workers, including medical treatment, lost wages, and other types of financial assistance.
• Northern Territory: The Workers Rehabilitation and Compensation Act 1985 and the Workers Rehabilitation and Compensation Regulations 2017 provide the legal framework for workers' compensation in the Northern Territory. The law requires employers to have insurance to cover the costs of work-related injuries and illnesses, and provides benefits to workers, including medical treatment, lost wages, and other types of financial assistance.
• Australian Capital Territory: The Workers Compensation Act 1951 and the Workers Compensation Regulation 2002 provide the legal framework for workers' compensation in the Australian Capital Territory. The law requires employers to have insurance to cover the costs of work-related injuries and illnesses, and provides benefits to workers, including medical treatment, and lost wages.