What Is Malingering, and How Does It Affect Workers’ Compensation?

Workers’ compensation exists to help injured employees recover while covering medical bills and lost wages. But sometimes, injured workers face the difficult accusation of malingering. Understanding what malingering is and how it can affect your workers’ compensation claim is important for protecting your rights and ensuring your claim is handled fairly.

Understanding Malingering in Fraudulent Workers’ Compensation Claims

It’s important to note that malingering is different from genuine injury or delayed recovery. Workers may legitimately experience ongoing pain and functional limitations that make returning to work difficult. Malingering, by contrast, involves a conscious effort to misrepresent symptoms to obtain benefits improperly.

How Malingering Is Identified in Workers’ Compensation Insurance Claims

Insurance carriers are on guard for workers’ comp fraud, which can include malingering. Common methods used to detect malingering include:

• Medical examinations. Insurers use independent medical exams (IMEs) that may reveal inconsistencies between reported symptoms and physical findings.
• Behavioral observation. Physicians and evaluators may observe inconsistencies in behavior or activity levels that do not match reported pain or limitations.
• Work history review. Past injury claims, litigation history, or suspicious patterns can raise red flags.
• Diagnostic testing. Functional capacity evaluations and other tests can help determine whether claimed limitations are supported by objective evidence.

While these measures are designed to prevent fraud, they can sometimes create tension for genuinely injured workers who are recovering more slowly than expected.

The Difference Between Malingering and Slow Recovery

Importantly, not every delayed recovery or ongoing pain indicates malingering. Many factors can affect recovery time. For instance, the severity of the original injury may require a lengthy recovery time with multiple surgeries, therapies, and treatments. Likewise, if a person has a pre-existing medical condition that is complicated by the injury or illness, their recovery time may genuinely be slower. 

In addition to the injury itself, a worker’s mental health may suffer, making it even more difficult for them to return to the workplace. Workers may experience real pain and limitations that appear inconsistent with objective tests, but that does not mean they are malingering. Mislabeling a worker can harm both the individual and the integrity of the claim process.

Why Malingering Matters in Workers’ Compensation

Being accused of malingering can have serious consequences. Insurance carriers may reduce or deny benefits if they suspect malingering or request an injured or ill worker to undergo additional medical evaluations that can be invasive and inconvenient. 

Even if you are fully honest about your injuries, a suspicion of malingering can complicate your claim. For these reasons, it’s important to document your symptoms, follow medical advice, and work closely with your doctor and attorney.

Tips to Protect Yourself from Malingering Accusations

To avoid being falsely accused of malingering in your workers’ comp claim:

1. Document Everything. Keep detailed records of your symptoms, treatments, medications, and functional limitations. Include daily journals if possible. This type of journaling helps you keep your list of limiting functions clear and helps you avoid oversimplified statements.
2. Follow Medical Recommendations. Attend all medical appointments, follow prescribed therapy, and maintain a consistent treatment plan. If your employer wants you to see a specific doctor or provider, you must visit that provider.
3. Be Honest and Detailed. Clearly describe your symptoms and limitations without exaggeration. Avoid vague statements like “I can’t do anything,” and instead specify activities that are difficult or impossible for you to perform.
4. Communicate with Your Attorney.  An experienced workers’ compensation attorney can guide you on documentation and communicating with insurance providers.

By being honest and communicating effectively, you can help reduce the risk that an insurer will attempt to accuse you of malingering. 

Common Misconceptions About Malingering

There are many myths surrounding malingering that can unfairly stigmatize injured workers. Possibly the most obvious myth is that a slow recovery automatically means an injured worker is malingering. The truth is that recovery varies widely depending on a plethora of factors, including the injury type and a person’s individual health. 

Most injured workers are honest. False claims are rare, but certain issues with a claim could make an insurer suspicious. If a doctor can’t measure the injured worker’s pain objectively, an insurer may suspect malingering. 

Unfortunately, many legitimate injuries do not show up on imaging or through the use of standard testing. 

When Malingering Accusations Cross into Workers’ Comp Fraud

While malingering itself is a symptom exaggeration, workers’ comp fraud occurs when someone intentionally misrepresents facts to receive benefits they are not entitled to. Falsifying medical records, claiming an injury occurred at work when it didn’t, and receiving benefits for a preexisting condition that was not aggravated by work are examples of workers’ compensation fraud. 

Fraudulent workers’ comp investigations are serious and can result in denied benefits, repayment obligations, or even criminal charges. Knowing the difference between legitimate claims and fraudulent behavior is key to protecting yourself.

How an Attorney Can Help with Your Workers’ Compensation Fraud Case

If you’re concerned about malingering accusations or filing a complicated claim, an experienced workers’ compensation attorney can help by gathering and organizing documentation to support your claim and handling the communication between you and the insurer. If the insurer denies your claim, an experienced attorney can handle an appeal. 

Having professional guidance ensures your claim is taken seriously and reduces the risk of false accusations affecting your recovery. 

Avoiding False Claims of Malingering 

Understanding malingering in the workers’ compensation realm can help you avoid false accusations from insurers. Most injured workers are honest, but insurance carriers remain vigilant against suspected fraud, and suspicion of malingering can complicate a claim.

By carefully documenting your injury, following medical advice, and working with a knowledgeable attorney, you can protect your benefits and ensure your recovery is properly supported.

A Workers’ Compensation Lawyer Can Help You Fight Back Against Provider Fraud and Receive Workers’ Compensation Benefits

If you have questions about malingering, workers’ comp fraud, or your rights under the workers’ compensation system, contact the experienced team at Pond Lehocky today to discuss your case.