This win highlights:
- The necessity to thoroughly review medical records submitted by treating doctors. Oftentimes, these records have a detailed history of the claimant’s prior medical history and treatment. This review, coupled with the history as given by a claimant in initial claim documents (C-3) and history as given by claimant to IME doctors could vary greatly, and very well may be the basis of a fraud finding by the Workers’ Compensation Board;
- The importance of seeking full medical records by way of subpoena in order to obtain the full picture of the claimant’s health prior to the workers’ compensation accident date; and
- How detailed fraud litigation can have an impact on the workers’ compensation case as well as a corresponding costly general liability claim.
Jones Jones LLC attorneys Dana Sabghir and Katherine Caracappa secured a major win for a construction company that resulted in the claimant paying a significant amount of money back to the carrier.
The claim involved a claimant construction laborer, who upon initial filings (C-3), denied any prior conditions or prior accidents. The claim was established for bilateral knees, elbow, and the back. Soon after this establishment of injury, the claimant’s attorney filed for a hearing with the intent of expanding the case to numerous body parts and conditions. Our Jones Jones LLC attorneys subpoenaed records from the doctors who had submitted medical evidence in support of expanding the case to numerous other body parts. Upon a thorough review of these records, it became evident that the injured worker actually did indeed have extensive prior treatment to the bilateral knees, elbow, and back. Additionally, these prior records made reference to multiple prior accidents, prior surgeries, as well as significant results on diagnostic tests pre-dating our injury date in question. The claimant had also begun denying prior injuries to several of his own doctors as well as the independent medical consultants on the case. The misrepresentation of the prior physical condition of the claimant was spread not just to the documentation filed with the NY Workers’ Compensation Board; but also to the doctors tasked with treating the claimant’s injuries.
Jones Jones LLC raised fraud under WCL Section 114-A and requested that the Law Judge enter a formal finding that the claimant committed a material misrepresentation. The fact that prior injuries, surgeries, and conditions were denied on the initial claim filing documents as well as denied to a variety of doctors during treatment and evaluation was the basis for this request for a fraud finding.
Following litigation, the Law Judge did find that the claimant violated Section 114-A fraud as the claimant committed a material misrepresentation as it related to his prior physical condition. The New York State Workers’ Compensation Board held that the claimant was required to pay the insurance company approximately $40,000.00 back in workers’ compensation benefits as well as be permanently disqualified from receiving future indemnity benefits.
Additionally, as the accident in question involved a construction site accident, the claimant had a corresponding general liability claim. The fraud finding on this claimant’s workers’ compensation case had had significant impact on the future of the claimant’s general liability claim and his ability to close that case with a monetary gain.
Contact our attorneys today at firstname.lastname@example.org for any need you have regarding a fraud evaluation.