2. Copyright © 2012 EMPLOYERS. All rights reserved.
EMPLOYERS and America’s small business insurance specialist are registered trademarks of Employers Insurance Company
of Nevada. Employers Holdings, Inc. is a holding company with subsidiaries that are specialty providers of workers'
compensation insurance and services focused on select, small businesses engaged in low-to-medium hazard industries.
The company, through its subsidiaries, operates in 31 states and the District of Columbia from 12 office locations.
Insurance is offered through Employers Insurance Company of Nevada, Employers Compensation Insurance Company,
Employers Preferred Insurance Company and Employers Assurance Company, all rated A- (Excellent) by the A.M. Best
Company. Coverage is not available in all jurisdictions and varies by company. See www.employers.com for coverage
availability.
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3. Ranney P. Pageler
V.P. Fraud Investigations Department
EMPLOYERS®
 Ranney has successfully referred
more than 600 criminal prosecutions
in 23 states for workers’
compensation fraud related crimes.
 Anti-fraud program has been the
subject of several news media
articles and broadcasts.
 Member of several anti-fraud
organizations and taskforces.
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4. Claimant Fraud Detection and Investigation
The Policyholder
Recognizes several “Red Flag” indicators of fraud:
 The claim was filed late (upon termination of employment).
 Injury was unwitnessed.
 The facts did not support the claimant’s own description of
accident.
 Medical treatment was initially declined by claimant.
Notifies the carrier of suspected fraud:
 Notified the claim examiner of the “Red Flags” for potential fraud.
 Claim examiner notified the EMPLOYERS Fraud Investigations
Department of the potential fraud issues.
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5. Claimant Fraud Detection and Investigation (Cont’d)
The Insurance Carrier
 Claim examiner coordinated the administrative claim handling,
while the EMPLOYERS Fraud Investigations Department
conducted a criminal investigation.
 Policyholder, employees and others were interviewed.
 Documentary evidence was identified and collected.
 Claimant’s previous claims history was obtained and reviewed.
 Claimant and witness statements were documented and
scrutinized.
 Any exculpatory evidence was identified, documented and
reviewed.
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6. Referral of Criminal Investigation Package to Law
Enforcement
The Insurance Carrier
 A formal report of investigation was prepared, documenting the
overt acts that demonstrated that the crime of workers’
compensation insurance fraud had been committed by this
claimant.
 The Investigation Report identified suspect(s), evidence,
witnesses, the amount of actual/potential loss and a timeline of
relevant events.
 The completed investigation “package”, including the report of
investigation and all evidence items was provided directly to the
appropriate law enforcement agency for further investigation.
 Communication was maintained between the claim examiner and
the EMPLOYERS Fraud Investigations Department to ensure
proper administrative handling of the claim.
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7. Prosecutorial Review and Criminal Charging
Law Enforcement and the Prosecutorial Agency
 Law enforcement independently investigated and substantiated the
facts, statements and evidence contained in the insurance carrier’s
investigative package.
 The Prosecutorial Agency assessed the criminal prosecution potential
following a referral from law enforcement.
 The prosecutor submitted a seven-count criminal complaint, with
affidavit in support thereof, to the court, which then issued a felony
arrest warrant for the claimant.
 The claimant then fled the country for a period of more than four years.
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8. Handling Fugitive Flight
The Insurance Carrier and the Prosecutorial Agency
 The insurance carrier had to check its records annually to
determine if any contact had been made with the claimant.
 The insurance carrier then had to annually notify the prosecutorial
agency that had filed the criminal complaint of its records’ search
and request that the arrest warrant remain active.
 The prosecutorial agency had to attempt annually to locate the
wanted fugitive and re-activate the warrant in the various national
and state law enforcement databases.
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9. Obtaining the Criminal Conviction
The Prosecutorial Agency
 The claimant was arrested during the commission of another
unrelated crime.
 The arresting agency discovered the outstanding felony warrant
during the jail booking process.
 The claimant was brought to the court that had issued the felony
arrest warrant where he ultimately pled guilty and admitted that
no industrial accident/injury had occurred.
 The claimant was sentenced to extended probation, ordered to
pay restitution and held in custody facing other criminal charges
and subsequent deportation.
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10. Totally Fraudulent v. Partially Fraudulent Claim
The Criminal Conviction Impact
 A totally-fraudulent claim is a claim where it can be proven that
the injury never happened or was never industrially related: both
the occurrence and the total amount of the claim is removed from
the policyholder’s experience modification history (as a non-
compensable claim), retroactively to the initial date of the
fraudulent claim.
 A partially-fraudulent claim is a claim where it can not be proven
that the injury never occurred, merely proven that the injury had
no effect on the claimant after a specific date: an occurrence
remains on the policyholder’s experience modification history, but
the amount of the claim is reduced by the amount of the fraud.
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11. Obtaining a Retroactive Positive Financial Result for the
Policyholder
The Insurance Carrier
 Amended Unit Statistical Reports were filed by the carrier,
retroactively removing the financial impact of the fraudulent claim
from the policyholder’s experience rating history, even after more
than six years had expired from the initial date of injury to the
date of criminal conviction.
 EMPLOYERS issued a refund check to the policyholder to cover
the adjustment of premium for the covered policy periods that had
been adversely effected by the fraudulent claim.
 All subsequent insurance carriers had to provide similar premium
refunds to the policyholder for the policy periods covered by
those carriers.
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12. What Did All of This Mean to the Policyholder?
The policyholder’s letter says it all:
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13. Contact
You may contact Ranney P. Pageler directly at
EMPLOYERS® Fraud Investigations Department:
Fraudfighters@employers.com
(800) 750-3939
While we can only handle suspected fraudulent cases for
EMPLOYERS policyholders, please feel free to contact us with
general workers’ compensation fraud questions. We can also
provide contact information to direct you to the appropriate
government agency or insurance fraud unit for your jurisdiction.
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