Red Flags That Should Trigger Surveillance on a Claim

Not every claim justifies surveillance, and not every red flag does either. But a well-established set of signals exists across workers' comp, disability, and bodily injury claims. These signals predict surveillance productivity well enough to put on a standard referral checklist. This post walks through them.

General Claim-Level Red Flags

Across lines of business, these signals recur on claims where surveillance later produces usable evidence:

• Late reporting. Delay between injury and reporting, without a clear explanation
• Unwitnessed injury. Injury reported with no witnesses in a setting where witnesses would normally exist
• Post-termination, post-discipline, or post-layoff claim. Claim filed shortly after an adverse employment event
• Subjective-only injury. Chronic pain, soft-tissue injury, stress, or cumulative trauma, where objective medical findings are limited
• Prior claims pattern. Multiple prior injuries or losses, often similar in nature
• Changing story. Account of the injury shifts between first notice, recorded statement, and medical records
• Representing attorney. Attorney is known in local claims practice for aggressive litigation on soft-tissue cases

Our insurance fraud red flags post covers the broader typology.

Workers' Comp-Specific Red Flags

• Refusal of light duty or modified work without a specific medical basis
• Failure to return work releases to the employer
• Pattern of missed medical appointments paired with social activity indicators
• Side-business listings on Yelp, Google, or social media
• Spouse employed in workers' comp-adjacent role (familiarity with the process)
• Monday morning or post-weekend injury claims

Disability Red Flags

• Active job search on LinkedIn while receiving disability benefits
• Business ownership registration during the benefit period
• Social media activity inconsistent with claimed limitations (travel, athletic activity, event attendance)
• New social or romantic activity inconsistent with claimed severity
• Self-employment or 1099 income indicators

Bodily Injury Red Flags

• Soft-tissue only injuries in collisions with minor property damage
• Multiple claimants in the same vehicle with near-identical injuries
• Treatment concentrated with a single provider known to the carrier
• Prior bodily injury history surfaced through ISO ClaimSearch

Social Media as a Red Flag Source

Social media investigation should precede surveillance on every serious file. Look for posts that show physical activity, employment status, or travel inconsistent with the claim. These are often enough to justify sub rosa. Our social media investigation post covers the process.

Medical Red Flags

From the medical record:

• Inconsistencies between Functional Capacity Evaluation (FCE) and reported symptoms
• Waddell signs or other clinical indicators of symptom magnification
• Medication-seeking behavior
• Multiple treating providers with similar fact patterns
• Delay in follow-up inconsistent with reported severity

Escalation Path

On claims where red flags stack up, the escalation path is usually:

1. Social media investigation (inexpensive, first-touch)
2. Activity check (confirm address, initial eyes-on)
3. Single-day sub rosa if the activity check is inconclusive
4. Multi-day or team sub rosa if the single-day raises specific inconsistencies but doesn't resolve the question
5. Fraud investigation case file if the accumulated evidence supports denial or referral

See activity check vs. surveillance for the first-step decision.

Reserves and Reserves

No matter how many red flags are present, surveillance cost needs to scale to claim reserves. The surveillance cost post covers the economics.

Triggering Events

Beyond standing red flags, specific events often trigger surveillance:

• Upcoming IME or QME
• Deposition scheduled
• Settlement conference approaching
• Return-to-work dispute
• Adjuster assigned a new file with pre-existing red flags

The Referral Packet

A good surveillance referral includes:

• Claim summary and reserves
• Claimant identifiers and photograph
• Address and vehicle information
• Red flag summary
• Specific investigative question(s) the surveillance is intended to answer
• Any known upcoming events (IME, deposition, etc.)
• Authorization and budget approval

Our surveillance and activity check services scope the right operation based on this referral packet. We also recommend when surveillance is, and isn't, the right next step.