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Case Study (F) - Claims Management - Construction Worker
Stage One: The worker was taking regular absences from
work and failing to upgrade his suitable duties.
Stage Two: Investigations identified the worker carrying
out normal duties elsewhere whilst indicating ongoing incapacity to his
Stage Three: The worker failed to present to work on the
duties offered. He abandoned his employment.
Stage Four: Some eight months after abandoning his
employment the worker lodged as claim for weekly wages back dated to his
last date of work. He also claimed high level of incapacity and benefits
This affected the employer by having an estimate and cost of claims of over
$140,000.00. This was just prior to the policy renewal.
The worker refused to upgrade, the employer asked for help. We liaised with
the insurer and investigations were deemed necessary. The worker was found
to be working elsewhere and clearly showing capabilities above what was
claimed. This information was provided to medical examiners. The doctors
supported a full return to work. The worker was then directed to work
The worker failed to comply instead he abandoned his employment. However
the process was documented and shown to be fair. The insurer closed the
claim with no large ongoing estimate and no estimate for wages.
Just prior to policy renewal the worker submitted documents through his
solicitors, which contradicted our knowledge of his status. The matter was
immediately addressed with the insurer and a further investigation was
undertaken resulting in evidence being obtained to support our client's
position. The worker had been working at various locations and had
fraudulently stated otherwise.
The insurer reduced the estimate by $76,000.00 immediately. The insurer
approved legal action to attempt a further $46,000.00 reduction. The worker
was forced to withdraw his claim for ongoing and past benefits due to the
information indicated by the investigation. The insurer is considering a
further recovery due to fraud legislation.
What the client say's
I am so glad this fellow didn't get away with this. Those additional costs
on my premium due to his claim would have been very difficult to meet.
Between this claim and the other that you got back to work you have saved
me a #### load of money.