Surveillance Video, Inconsistent History, and the Fraud Referral Decision
A Ketchikan worker with an accepted knee claim is receiving TTD and reports that he cannot bear weight, cannot climb stairs, and uses a cane. The adjuster orders surveillance after a tip. The video shows the worker carrying groceries up a flight of stairs, loading a truck, and walking without a cane on two separate days. The worker's treating physician had based the off-work restriction on the worker's reported symptoms. The worker also failed to disclose on his intake form a prior knee injury from five years earlier that had resolved. The adjuster has the video, the intake form, and the prior medical records. The worker has not yet been confronted.
1. Evaluate how the adjuster should use the surveillance video and the inconsistent history in deciding whether to continue, modify, or terminate benefits.
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The video and the inconsistent history are significant, but the adjuster should proceed methodically:
- Send the video and the prior records to the treating physician and ask whether the observed activity changes the work restrictions; the physician's restriction was based on reported symptoms, so the physician needs the objective information to reassess.
- Compare the video dates to the TTD period and document exactly what the worker was doing, for how long, and whether it is inconsistent with the stated restrictions.
- Treat the undisclosed prior knee injury as a credibility issue and investigate whether it is related to the current condition; do not assume it is dispositive.
- If the physician revises the restrictions or releases the worker, modify or terminate TTD with a timely notice and a specific basis.
- Do not terminate benefits based on the video alone without a medical reassessment, because the compensable condition and restrictions are medical questions.
2. What are the adjuster's obligations regarding a potential fraud referral, and what should the adjuster avoid doing?
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The adjuster should document the inconsistencies and consult the carrier's special investigation unit and the applicable fraud-reporting framework. If there is a reasonable basis to believe the worker made a material misrepresentation to obtain benefits, the matter may be referred for investigation or prosecution under the applicable fraud statutes.
The adjuster should avoid:
- Confronting the worker in a way that could be seen as coercion or that tips off the worker before the investigation is complete.
- Making accusations of fraud in the file or to the employer without a documented factual basis.
- Using the fraud allegation as a substitute for the medical reassessment; benefits decisions must still rest on the medical evidence and the statute.
- Ignoring the possibility that the worker's activity is consistent with his restrictions on good days, which is why the physician's review is essential.
The adjuster's duty is to investigate thoroughly, document objectively, and refer through proper channels rather than to adjudicate fraud personally.
3. The worker later says he climbed the stairs slowly and was in pain afterward. How should the adjuster weigh that explanation?
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The explanation should be documented and evaluated against the video and the medical evidence rather than dismissed. Relevant questions:
- Does the video show the worker performing the activity in a manner consistent with his claimed limitations (for example, using the railing, pausing, limping)?
- Did the worker report post-activity pain to his physician, and does that change the physician's assessment?
- Is the explanation consistent with the prior statements and the intake form?
The adjuster should send the explanation to the physician along with the video and ask for an updated opinion. If the physician maintains the restrictions, the carrier should continue benefits; if the physician revises them, the carrier may modify benefits with a timely notice. The explanation affects credibility but does not by itself resolve the medical question, and the adjuster should keep the analysis factual and documented.