Workplace Injury & Bodily Injury Claim With Coordination Indicators: A Case Study

Industry: Workers’ Compensation & Liability

Engagement Type: Independent Claim Analysis Client: U.S.-Based Carrier

1. Background

The carrier referred a workplace injury claim for independent review after identifying unexpected similarities between the reported incident and a separate claim filed by another employee at the same worksite.

The referral was based on claim-level pattern recognition only.

Claim Analysis Group (CAG) was provided access to one claim file, the first employee’s claim and no access was granted to the second employee’s claim.

2. Claim Overview

The reviewed claim involved an employee who alleged that he had fallen from a scaffold resulting in injury. The incident was captured on camera, and the employee was transported to a hospital for treatment.

Following the incident:

• A workers’ compensation claim was filed

• A third-party bodily injury (BI) claim was also filed

• The employee retained separate legal counsel for the workers’ compensation and BI claims

At face value, the claim appeared supported by video footage and medical treatment records.

3. Reason for Referral

The carrier requested independent analysis after noting that:

• Another employee had filed a claim involving the same scaffold

• The reported incident shared unusual similarities with the subject claim

• The similarities warranted review of the first claim for coordination or escalation indicators

CAG’s review was limited to the first employee’s claim file only.

4. CAG Scope of Work

CAG was engaged to:

Review the subject employee’s workers’ compensation and BI claim materials

• Assess internal consistency of the claim narrative and escalation pattern

• Evaluate legal representation and medical treatment indicators

• Identify inconsistencies relevant to claim handling and litigation strategy

All work was conducted independently using:

• Materials contained within the subject claim file

• Publicly available information

• No conclusions were drawn regarding any other claims.

5. Investigative Methodology

CAG applied a structured, human-led review using publicly defensible investigative techniques.

5.1 Incident & Narrative Consistency Review

CAG reviewed:

• The reported mechanism of injury

• Video footage of the incident

• Claim narratives submitted across claim types

The review identified internal consistencies and escalation timing relevant to claim evaluation.

5.2 Representation Review

CAG conducted public-source research on legal counsel retained by the subject employee, reviewing:

• Publicly available business registration information

• Office address data

• Reported disciplinary or investigative history

The review determined that:

• Counsel retained for the workers’ compensation and BI claims operated from the same building address

• Representation patterns were relevant to escalation analysis

No conclusions were drawn regarding representation associated with any other employee.

5.3 Medical Treatment Pattern Review

CAG reviewed medical records and billing information associated with the subject employee’s claim to assess:

• Treatment volume relative to the reported mechanism of injury

• Repetition or overlap in services

• Indicators of potentially excessive, unnecessary, or unreasonable treatment

Publicly available information indicated that certain medical providers involved had been subject to prior scrutiny related to treatment practices. This information was documented as context only, not as a determination.

5.4 Claimant History Consistency Review

CAG reviewed publicly available records related to the subject employee’s prior injury and claim history.

The analysis identified:

• Prior claims relevant to credibility assessment

• Inconsistencies between sworn testimony and publicly available records regarding prior accidents

6. Key Findings

CAG’s analysis concluded that, within the subject claim file:

• Claim escalation followed a structured pattern across claim types

• Separate legal counsel was retained for workers’ compensation and BI claims

• Medical treatment patterns raised concerns regarding proportionality

• Certain claimant statements were inconsistent with publicly available records

CAG did not evaluate or draw conclusions regarding any other employee’s claim.

7. Outcome

Based on CAG’s documented findings:

• The carrier strengthened its claim-handling and litigation strategy

• Treatment reasonableness concerns were preserved for review

• Inconsistencies were documented to support defensible decision-making

• Legitimate aspects of the claim were evaluated independently of identified concerns

8. CAG Value Delivered

• Scope Discipline: Analysis confined strictly to authorized materials

• Independent Review: No system access or IT integration required

• Evidence-Based Documentation: Findings supported without speculation

• Litigation Awareness: Preserved relevant inconsistencies responsibly

9. Key Takeaway

Effective investigations respect boundaries as much as they uncover facts.

By focusing exclusively on the authorized claim file while acknowledging external indicators, CAG provides clarity without overreach.