Fraud Case Studies

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The Insurance Commission has a zero tolerance approach to fraudulent activities and will pursue those engaged in fraud or attempts to defraud. 

Please report fraud. After all you’re paying for it.

Prosecution is not the Insurance Commission’s yardstick for successfully preventing fraud, but it is a public means of measuring success. The following case studies present examples of successful outcomes of fraud prosecutions.

Falsely declaring inability to work

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Case Study 1

In 2016, a claimant was involved in a car accident and claimed a total incapacity to return to work. Surveillance footage obtained showed the claimant working on two separate occasions in March 2017.

On  22 June 2017, the claimant submitted a Past Loss of Earning Capacity (PLEC) request for an advanced payment from 28/02/2017 to 11/04/2017, stating that he had not worked during this period. His settlement offer also mentioned this same period of alleged incapacity.

Payslips obtained and a witness statement confirmed that the claimant had returned to work on 27 March 2017. The claimant attempted to obtain a total of $1451.30 net compensation from the Insurance Commission he was not entitled to, for period 27/03/2017 to 11/04/2017.

The claimant pleaded guilty to providing false or misleading information and was fined $1,000 and $945.35 costs.

Case Study 2

A claimant alleged to have suffered from severe depression, with associated neck, low back and total body pain after being in two car crashes on 30 April 2015 and 7 March 2016.

Surveillance footage of the claimant over 7 days between 09/11/2016 and 05/06/2017 showed that the claimant had a physical capacity contrary to their claim.

The claimant pleaded guilty to providing false or misleading information to a medical specialist and was fined $3,000 and ordered to pay $2,044 costs.

Case Study 3
In 2016 a claimant was involved in a crash and claimed that the physical injuries they sustained prevented them from returning to work. The claimant submitted a Notice of Intention to Make a Claim form in June 2017 and stated that they had not been able to return to work since the crash.

Surveillance footage and data obtained from their employer showed that the claimant had been working full time since March 2017. The claimant was taken to court for providing false or misleading information and pleaded guilty. They were given a $2000 fine, $744.35 costs and a spent conviction.

Case Study 4

In 2016, a claimant suffered a lower back injury as a result of a motor vehicle crash. The claimant sought $23,180 in damages, claiming they were unable to work in their usual profession from the period 22/01/2017 to 17/08/2017.

Evidence gathered by Fraud Investigations revealed the claimant had been working since April 2017.

The claim settled for $20,000.

Case Study 5
In 2011, a claimant stated that their injuries from a car crash prevented them from carrying out their usual work duties and ultimately led to them being let go. The claimant sought $1,074,415 in compensation for loss of earnings, which included $780,000 for future loss of earnings.
Fraud Investigations gathered evidence that established that the claimant ceased working in 2013 because their contract was not renewed and not because of their inability to perform their usual work duties. Evidence also revealed that the claimant had falsely provided information about what their usual work duties were in order to increase their financial settlement.

The claim was settled for $300,000.

Case Study 6
In 2018, a claimant submitted an invoice for reimbursement of a pair of trainers costing $279.99. Enquiries by Investigations and Intelligence revealed that the shoes had already been returned to the store for a full refund.

The claimant was charged with attempting to gain benefit by fraud and received a $500 fine.

Case Study 7

A claimant alleged that they had received significant neck, shoulder, check and back pain as a result of a car crash in August 2016 In 2017, the claimant attended a medical assessment and advised that they had been unable to work in any capacity since the crash.

Hours of Surveillance footage obtained by the Investigations and Intelligence team showed the claimant working in their self-employed café business between 23/01/2018 and 03/05/2018.

The claimant was found guilty of providing false or misleading information and fined $3000 with costs of $713.30.

Case Study 8
In 2019, a claimant attended two medical assessments and advised they had not been able to return to work since their crash in 2016 because of the extent of their injuries.

Surveillance obtained by Investigations and Intelligence over the period January 2019 to February 2019 showed evidence that the claimant had returned to work in full capacity.

The claimant was charged with providing false or misleading information to the Insurance Commission and fined $2000 and $1,141.40 in costs.

Case Study 9
In 2016, a claimant was struck by a vehicle and claimed to have received injuries that prevented them from returning to work.

The claimant received regular advance compensation payments from the Insurance Commission throughout their claim. In 2019, the claimant attended two medical assessments and maintained that they had not worked since the crash in 2016.

Tipped off by a member of the public, the Investigations and Intelligence team carried out months of surveillance. The surveillance footage obtained showed the claimant working at a construction site from 19/01/2019 to 05/06/2019, which contradicted what they had claimed.

The claimant was fined $2000 and ordered to pay $10,000 in costs.

Case Study 10

A claimant alleged they had neck, chest and back injuries and significant psychological symptoms following a crash in 2016. The claimant claimed a total incapacity to return to work.

Surveillance conducted by the Investigations and Intelligence team showed evidence of the claimant working as a barber at various stages during the course of their claim. The surveillance footage also showed the claimant displaying physical and psychological capabilities that contradicted their claims.

The claimant was charged with providing false or misleading information to the Insurance Commission and fined $4000 plus $1400 in costs.

Case Study 11

A claimant was involved in a motor vehicle crash in 2019, sustaining facial and back injuries. The claimant attended a medical assessment in 2021 and alleged a total incapacity to work as well as significant restrictions leaving the house and driving due to psychological symptoms caused by the crash.

The Insurance Commission received a tip-off from a member of the public that they had seen the claimant driving and working in secret as a mechanic. Surveillance footage obtained showed the claimant working as a mechanic and driving various vehicles, despite having a suspended driver's license.

The claimant was charged with providing false or misleading information to the Insurance Commission and fined $3500.

Fraudulent workers’ compensation claim

Case Study 12

A claimant working as a clinical nurse at a public WA Hospital lodged a workers’ compensation claim after a workplace injury. Prior to the injury, the claimant was also employed part time at a nursing home.

The claimant received compensation to cover his wages from 2010 to 2012 and top-up payments for his second job. While receiving loss of wages payments from the Insurance Commission, the claimant returned to employment at the nursing home, allegedly defrauding the Insurance Commission by failing to declare his employment.

During medical assessments, the claimant also failed to disclose his work.

A Fraud Investigations enquiry revealed the claimant was overpaid $112,175 in compensation payments. The claimant was charged with Fraud by Western Australia Police and civil recovery action commenced to recover overpayments

Case Study 13

In 2012, the claimant, a prison officer, was struck in his lower back by a large metal object. He reported the incident to his employer but only sought medical treatment a week later due to a gradual increase of pain over that period. The claimant responded well to treatment and was deemed fit to return to work, undertaking modified duties.

In 2013, the claimant’s injury recurred and he submitted a medical certificate to the Insurance Commission from another company. The Insurance Commission nor the employer were aware of the secondary employment.

In 2013, Fraud Investigations conducted surveillance of the claimant participating in a surfing competition despite claiming to be unfit for work due to his recurring back injury. The claimant resigned when presented the evidence. Fraud Investigations referred the matter to the Corruption and Crime Commission due to suspected dishonesty by a public officer and to WorkCover WA to investigate alleged breaches to the Workers Compensation and Injury Management Act 1981.

Provider overbilling the Insurance Commission

Case Study 14
In 2009, a nurse providing care to a catastrophically injured claimant, billed the Insurance Commission for services that were not provided, as did her husband. He was found guilty of eight counts of fraud and fined $1000. The nurse pleaded guilty to fraud charges, was given a two-year intensive supervision order and required to pay back nearly $20,000.

Page Last Updated 17 Jul 2023

Media contact

Amber Blake
A/g Senior Communications Officer
+61 8 9264 3227

amber.blake@icwa.wa.gov.au

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