Work Injury Attorney: What to Do If Your Claim Is Under Investigation

A workers’ compensation investigation can be unnerving. One day you are focused on getting better, the next you are fielding calls from an adjuster, signing medical releases, and hearing that a private investigator might be watching your driveway. I have represented injured workers for years, from warehouse employees with torn rotator cuffs to nurses with repetitive stress injuries to electricians dealing with spinal fusion surgery. When a claim goes “under investigation,” it does not mean you have done something wrong. It means the insurance carrier is looking for reasons to limit or deny benefits. How you respond in the first few weeks often sets the tone for the entire case.

What follows is a practical walkthrough of what investigations involve, how to protect your credibility, and when to bring in a workers compensation lawyer. Regulations and timelines vary by state, but the fundamentals of preserving evidence, managing medical care, and controlling communication are similar across jurisdictions.

Why carriers investigate even straightforward injuries

Insurers investigate for two core reasons: risk and leverage. Workers’ compensation is a no-fault system, so the carrier rarely argues about who caused the accident. Instead, they scrutinize whether the injury is work related, whether the reported mechanism of injury matches the medical evidence, and whether the treatment is reasonable and necessary. In high-cost cases, a thorough review is almost automatic. Claims with surgeries, long time off work, or disputed histories are more likely to trigger surveillance, employer interviews, and independent medical exams.

I once represented a delivery driver who herniated a disc lifting a 70-pound crate. The employer promptly reported the claim, and the emergency room note documented acute lumbar pain. Two weeks later, the adjuster flagged inconsistencies between the initial pain diagram and a later physical therapy note. That alone was enough to justify deeper review. Not because the worker lied, but because minor charting differences can be used to argue the injury worsened outside of work or that symptoms are exaggerated. Investigations look for gaps, no matter how small.

What “under investigation” actually looks like

The term sounds ominous, but it usually means the insurer is gathering records and asking questions within a defined window. States often give carriers 14 to 45 days to accept, deny, or pend a claim while investigating. During that time you might see several things happen at once.

Adjuster interviews are common. Expect a recorded statement with questions about your job duties, how the injury occurred, prior injuries, hobbies, and medical history. Surveillance may start quickly in higher exposure cases, especially around scheduled medical appointments. Background checks will sweep your social media and any publicly accessible postings for inconsistent activity. Medical records requests can be broad, sometimes reaching several years back. The insurer will also request a signed medical release, and in many states you must cooperate within reason to keep benefits moving.

None of this means the insurer is out to get you. It does mean they are looking for inconsistencies they can use. If you tell the adjuster you cannot lift more than 10 pounds, then post a photo hoisting a kayak the same weekend, expect that to appear in a denial letter. I have seen adjusters try to use a decade-old chiropractic visit to argue a knee injury was preexisting, even when MRI findings were clearly acute. The investigation is a filter. Your job is to provide accurate, consistent information and avoid avoidable mistakes.

First priorities in the early days

Medical care comes first, not paperwork. Get evaluated by a provider, preferably the day of the incident. If your state allows you to choose your own physician, pick one familiar with occupational injuries. If your state requires an employer panel or authorized clinic, follow that protocol while documenting every step. Insurers pay more attention to initial records than anything else. The first notes will be quoted in letters and hearings.

At the same time, report the injury in writing to your employer, even if you already told your supervisor. A brief email that states the date, time, task, and body parts involved is enough. Include names of any witnesses. If there was defective equipment, a wet floor, or an awkward lift due to short staffing, note that too. Facts beat adjectives. “Slipped on oil by Dock 3 at 8:15 a.m., right ankle twisted inward” is far more useful than “hurt ankle during morning shift.”

Save what you can. Photos of the scene, your work boots, a broken ladder rung, or the exact box you lifted will matter later. Keep copies of every medical visit summary, work restriction note, and diagnostic order. Start a simple log with dates, who you spoke with, and key takeaways. When a claim goes under investigation, details get replayed months later. Your memory will thank you.

Handling the recorded statement without hurting your case

Most states allow or require the adjuster to take a recorded statement. Go in prepared. Review your initial report and the first medical note. Know your job duties in plain terms. If you lifted 30 to 40 pounds repeatedly, say that, not “heavy stuff.” Avoid guessing. If you don’t remember whether your foot slipped before or after the twist, say you’re not certain. Honest uncertainty is better than confident speculation that later turns out wrong.

You can ask to reschedule if you are on heavy pain medication or just out of surgery. Clarity matters more than speed. You also have the right to have a work injury attorney or workers comp attorney with you. Many of my clients feel calmer when we sit in, not to obstruct, but to catch unclear questions and ensure the record reflects the mechanism of injury accurately. The adjuster’s job is to narrow your statements. Your job is to tell the truth cleanly.

Be ready for questions about prior injuries. A past ache is not the same as a prior diagnosed tear. If your shoulder was sore for a week two years ago after yard work, say so, and say it resolved. If you have a degenerative condition, that does not bar benefits. Aggravations of preexisting conditions are compensable in many states when work is a substantial factor. Precision beats defensiveness.

The trap of unfettered medical releases

Carriers often send a medical authorization that opens your entire history. You generally must allow reasonable access to records related to the injury. You do not have to consent to a blank check. It is fair to limit the timeframe to a few years prior and the body parts at issue. If the claim involves a back injury, a request for dermatology records from a decade ago is a stretch. Overbroad access invites cherry-picked notes that complicate things unnecessarily.

A workers compensation attorney can negotiate appropriate scope quickly. I have had adjusters agree in minutes to narrow requests once we pointed out the mismatch. If they refuse, your state may have a dispute process where a judge or board member can set boundaries. The key is to respond rather than ignore. Silence is often treated as non-cooperation.

Surveillance and social media: assume you are being watched

Surveillance is common in claims with surgery, injections, or long periods of wage loss. Investigators often watch on weekends and Worker Injury Lawyer Abogados de Compensación Laboral around medical visits. They are not looking for you to run a marathon. They are waiting for five seconds of footage that can be played on repeat to imply you can work full duty. I once saw video of a client loading a cooler into a car. The clip looked damning until we obtained the full video showing his neighbor lifting the heavy end. Context saved the case, but the stress could have been avoided.

Social media is a softer version of the same tactic. A smiling photo at a nephew’s birthday can be spun as evidence of no depression. A catch with your child can be cast as evidence of shoulder function. Adjust your privacy settings and avoid posting about activities, travel, or the case itself. Ask friends not to tag you for a while. Better yet, go quiet until the investigation ends.

If the adjuster schedules an independent medical examination, understand the exam is not truly independent. The doctor is selected by the insurer and often performs dozens of these reviews each year. Some are fair, some are not. Your job is to prepare like you would for an important job interview. Bring a concise timeline of the injury, treatment to date, and current restrictions. Be courteous and consistent. Do not minimize pain, and do not overstate. If certain movements hurt after five minutes, say so and stop when you reach that limit.

Consider bringing a spouse or friend as a witness, if your state allows it, or at least take notes immediately after the exam. Document the duration, what tests were performed, and anything unusual. I have seen IME reports claim a 30-minute exam that lasted exactly seven minutes. Notes and timestamps can help your workplace injury lawyer challenge credibility later.

Light duty offers and return-to-work dynamics

While the insurer investigates, your employer may offer light duty. If the duties match your medical restrictions, refusing can jeopardize wage loss benefits. If the offered tasks exceed restrictions, or the position is make-believe busywork designed to push you out, document the misfit. Ask for a written description, compare it with the restrictions, and bring the document to your next medical visit. Have the doctor adjust or reaffirm restrictions based on actual job demands. I have seen a simple clarification from a treating physician undo a denial that was about to snowball.

Be alert to subtle pressure. A supervisor suggesting you “tough it out,” take sick time instead of comp, or delay the formal report until after the holiday is not doing you a favor. Those delays become gaps that insurers exploit. Politeness is fine. Silence is not.

How credibility is built, one document at a time

Credibility is not a speech. It is a pattern. When your initial report, recorded statement, medical notes, and physical therapy progress reports all describe the same mechanism and symptoms, your case becomes simpler to approve. Small contradictions invite bigger fights. You can control this with careful language and steady habits.

Use the same descriptors for the same pain. If your wrist tingles and your thumb is numb, say that consistently. Stay on top of appointments. Missed visits appear as noncompliance. If you must cancel, reschedule and note why. Keep work restrictions visible, ideally a copy for your supervisor and one taped inside your locker. Email is your friend. Confirm conversations with short, factual notes to create a paper trail.

When to bring in a work injury lawyer

You do not need a lawyer for every bruised shin. But the moment your claim is pended, your benefits are late, or the adjuster asks for a broad recorded statement and release, a consultation with a workers compensation lawyer is wise. Most workers comp attorneys work on contingency or capped fee structures set by statute, not hourly rates. In many states, the fee is a percentage of disputed benefits, and uncontested medical bills are not reduced by attorney fees.

If your case involves surgery, permanent impairment, prior injuries to the same body part, alleged intoxication, or surveillance, the upside of counsel outweighs the cost. A seasoned work injury attorney coordinates medical documentation, prepares you for statements and IMEs, and spots traps early. Just as important, they push the claim through bottlenecks. Adjusters handle large caseloads. Files with persistent, informed follow-up often get faster decisions.

I once took over a case where a warehouseman had been waiting eight weeks for an MRI authorization while “under investigation.” We obtained a treating doctor letter tying the mechanism of injury to the proposed imaging, filed a motion to compel, and the MRI was approved within five days. The scan showed a labral tear. Delay is not neutral. It can shift the course of your recovery.

Common reasons carriers deny after an investigation

Patterns repeat. Understanding them helps you prepare.

Late reporting is a frequent issue. If you waited a week to tell your employer because you thought pain would resolve, the insurer argues the injury happened at home. Bridge the gap with a clear explanation and corroborating witnesses or text messages to a supervisor. Inconsistent histories derail claims. If triage notes say right shoulder and later notes mention left shoulder, expect questions. Correct the record quickly. Preexisting conditions are often cited. Distinguish prior aches from new structural damage, and get a physician to address aggravation explicitly. Non-cooperation can be alleged when you miss an IME or refuse a reasonable release. Communicate conflicts and propose alternatives in writing. Surveillance snippets without context appear in denial letters. If you think you were followed, tell your attorney. Context, and sometimes full footage, can neutralize the clip.

Medical evidence that actually moves the needle

Treating physician opinions carry weight, but only when specific. A two-sentence note that says “patient cannot work” doesn’t persuade. A good note ties mechanism to diagnosis, explains objective findings, and sets functional limits in measurable terms. For example, “Patient sustained acute L5-S1 disc herniation while lifting 70-pound crates at work on 5/2. Positive straight-leg raise at 30 degrees on the right, diminished Achilles reflex, MRI confirms right paracentral herniation impinging S1 nerve root. Restrictions: no lifting over 10 pounds, no bending or twisting, sit-stand option every 20 minutes.” That level of detail answers the insurer’s questions before they ask them.

If your doctor is pressed for time, a work-related injury attorney can request a short narrative report with targeted prompts. These reports are often the difference between an approval and a continued pend.

What to do if your benefits are stalled during the investigation

If your claim is in limbo and you are not receiving wage replacement, check state timelines. Many jurisdictions require the insurer to start paying temporary benefits while they investigate, unless there is a reasonable basis to withhold. If payments are simply late, a polite but firm written request referencing the statute or administrative rule can help. If they refuse and you qualify, your attorney can file for a preliminary conference or expedited hearing. These quick settings often produce interim orders for medical care or wage benefits while the full dispute proceeds.

If transportation or pharmacy access is a barrier, ask the adjuster about pre-approval processes or vendor arrangements. In some states, carriers must reimburse mileage to medical appointments. Save receipts. Practical friction often goes unaddressed because injured workers do not realize these small items are compensable.

Dealing with employer pressure or retaliation

Most states prohibit retaliation for filing a workers’ compensation claim. That does not stop subtle tactics: reduced hours, unpleasant shifts, or hints that “team players” work through pain. Document any adverse change that starts after the injury report. If you are fired shortly after filing a claim, flag that immediately. The comp system may not directly remedy retaliation, but employment laws might. A job injury attorney who understands both arenas can coordinate a response that protects your income and the integrity of your workers’ comp case.

If the insurer denies after the investigation

A denial is a comma, not a period. You typically have the right to appeal to an administrative judge or board. Deadlines are strict, often 20 to 30 days. The first appeal stage focuses on medical evidence and witness credibility. This is where a workers comp lawyer earns their keep: selecting the right medical expert, organizing records, preparing testimony, and negotiating a settlement if appropriate.

Do not rush to a low settlement out of frustration. I have seen claims denied for months suddenly become viable after a strong independent medical opinion ties findings to the incident. Sometimes a brief hearing exposes weak surveillance or highlights an adjuster’s misunderstanding of the job’s physical demands. On the other hand, if the medicals are thin, a reasonable compromise can spare you another six months of uncertainty. Strategy depends on evidence and your tolerance for delay.

Practical do’s and don’ts during the investigation

Here is a short, focused checklist that I give clients when a carrier pends a claim:

Report the injury in writing, keep copies, and note witnesses by name. Get prompt medical care and follow restrictions to the letter. Keep communications factual, short, and consistent across all platforms. Limit social media and assume you could be observed in public. Consult a workplace injury lawyer early if surgery, denials, or complex histories are involved.

How a good attorney manages the moving parts

A capable workers compensation attorney acts like a project manager for your recovery. They coordinate treating physician narratives, make sure diagnostic codes match the legal theory, and time requests so authorizations do not lapse. They prepare you for a recorded statement in a way that preserves truth and shields you from ambiguity. They narrow medical releases to fair scope and push back on irrelevant fishing expeditions. They address light duty mismatches with written job descriptions and doctor clarifications.

A good workplace accident lawyer also manages expectations. Recovery is rarely a straight line. People plateau in physical therapy, then improve after injections, then plateau again. Benefits can stutter even when everyone is acting in good faith. When an adjuster changes, the case can reset. Your on the job injury lawyer keeps momentum by tracking deadlines, filing prompt motions, and staying three steps ahead.

Edge cases and judgment calls

Not every case follows the script. If your injury developed gradually, like carpal tunnel or tendinosis, the insurer will probe for non-work activities. Typing at home, video games, musical instruments, home repairs, and sports can all be cited as alternative causes. The answer is not to deny your life. It is to quantify exposures. A credible occupational medicine opinion that compares hours and force levels at work versus home is powerful. A job injury attorney can frame the question correctly so the doctor’s report addresses legal standards like “major contributing cause” or “substantial contributing factor,” which differ by state.

If you have concurrent employment, benefits calculations get tricky. Some states aggregate wages, others do not. If the insurer understates your average weekly wage, your temporary benefits and any permanent impairment payout will be undervalued. Bring pay stubs from all jobs to your lawyer. Small numbers multiplied over months add up.

If your immigration status is complicated, know that many states provide workers’ compensation benefits regardless of documentation. Do not assume you are unprotected. I have represented undocumented workers who received full medical care and wage replacement. Confidentiality and careful planning matter, but the system is designed to cover workplace injuries without regard to citizenship.

Preparing for the long game without losing your bearings

Investigations end, but serious injuries can last. Think beyond the next check. If your work capacity will be permanently reduced, start documenting transferable skills and realistic job targets with your treating providers. Vocational rehabilitation, where available, can be invaluable, but it requires engagement. If your employer cannot accommodate restrictions, a clean record of cooperation strengthens your position at settlement or hearing.

Pain and uncertainty can fray patience. Build a small support system. A trusted coworker who will testify truthfully about the job’s physical demands. A family member who can drive you to an IME so you arrive calm. A primary care doctor who, while not the authorized comp physician, can still monitor overall health. Injuries isolate people. Isolation breeds mistakes.

Final thought for those staring at the “under investigation” notice

Being investigated is not an accusation. It is a phase, and it can be managed. Anchor everything to the basics: prompt care, precise communication, preserved evidence. Use specialists when the terrain gets steep. A work injury lawyer who has seen your fact pattern a dozen times can spot shortcuts and steer you around avoidable fights. Your role is to be the most credible person in the file, and that is built through calm, consistent actions over time.

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Pub: 24 Oct 2025 13:37 UTC

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