A rather typical business story became a head-scratcher of a Workers' Comp claim — and an illustration of the power of predictive modeling — when a seemingly “normal” claim was flagged for potential fraud.
A person traveling for business stayed in a hotel, as many people do when they travel, but with a twist. He filed a Workers' Compensation claim for supposedly suffering an injury after falling off a chair in his room. According to the claimant, he could no longer work, but he didn't expect that a predictive modeling tool would flag his case based on his occupation and other factors, bringing it to the attention of the insurer's Special Investigations Unit (SIU).
After a little digging, an SIU investigator found that the claimant had not reported the incident to the hotel and did not have any doctor bills. And when the investigator interviewed the claimant at his home, he spotted a broken chair on the outside patio. The claimant noticed that the investigator saw the chair, and immediately told the investigator that he wanted to withdraw the claim. Although there was no apparent reason for the claimant's reaction, the investigator suspected that the claimant may have injured himself falling off this chair at home, not a chair at the hotel.
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