Today’s topic is fraud. Attorney Christian Sison welcomes New York defense litigator Usra Hussain to the show to discuss fighting fraud in New York workers’ compensation claims. Can employers prove that claimants “knowingly” violate Section 114-a? Is it always beneficial to raise fraud at the outset of a claim? The episode ends with Usra taking her turn at “Guess the Outcome”! Continue reading Fraud – Third Fridays Podcast
New York State workers’ compensation fraud may take many forms and result in a myriad of consequences. WLC § 114(a) not only governs circumstances of fraud but also describes significant penalties for those who are caught committing fraud such as a permanent ban on their eligibility to receive indemnity benefits and/or a permanency award.
WCL § 114(a) directs that a claimant is to be penalized if he or she “knowingly makes a false statement or representation as to a material fact . . . .” in furtherance of receiving workers’ compensation benefits. This mandatory penalty is a forfeiture of all compensation that is directly attributed to the false statement. Workers’ compensation fraud penalties only apply to indemnity benefits and permanency awards, paid medical benefits are not subject to forfeiture in a fraud determination. See Jacob v. New York City Transit Auth., 26 A.D.3d 631, 809 N.Y.S.2d 618 (App. Div. 2006); Matter of Robinson v. Interstate Natl. Dealer, 50 A.D.3d 1325 (3rd Dept. 2008).
Pursuant to WCL § 114(a):
“If for the purpose of obtaining compensation pursuant to section fifteen of this chapter, or for the purpose of influencing any determination regarding any such payment, a claimant knowingly makes a false statement or representation as to a material fact, such person shall be disqualified from receiving any compensation directly attributable to such false statement or representation.”
Continue reading False Statements Made in New York State Workers’ Compensation Claims Can Lead to Forfeiture of Right to Receive Future Benefits
- Claimant denies having gainful employment while collecting temporary disability benefits. He actually started up a small business, but the business lost money.
- Claimant says he applied for jobs at 34 different businesses while seeking benefits. The employer performed its own follow-up search and learned he applied for only two (2) jobs.
- Claimant lying about his physical restrictions to our IME doctor
- Concealing volunteer work while “too disabled” to do your regular job?
- Caught selling street drugs while collecting workers’ compensation benefits?
- Claimant first admits to working, but her attorneys later state she isn’t. Claimant later found working seasonally while collecting benefits.
Continue reading Is this Workers’ Compensation Claim Fraud in New York?
In New York, pursuant to Workers’ Compensation Law § 114-a (1), a claimant may be disqualified from receiving workers’ compensation benefits “[i]f for the purpose of obtaining compensation . . . or for the purpose of influencing any determination regarding any such payment, [he or she] knowingly makes a false statement or representation as to a material fact.” A fact is “material” if it is “significant or essential to the issue or matter at hand,” and it need not be demonstrated here that claimant received compensation to which he was not otherwise entitled or that he did not sustain a compensable injury (Matter of Losurdo v Asbestos Free, 1 NY3d 258, 265 .
Recently the Third Department of the New York Appellate Division entertained an appeal in which the claimant was disqualified from receiving future benefits and forced to pay back past benefits as a result of violating Workers’ Compensation Law § 114-a, therefore committing fraud. The case, Matter of Poupore v Clinton County Highway Dept. 2016 NY Slip Op 03037 was decided on April 21, 2016. In this case, the penalty imposed by the Law Judge and the Board Panel was upheld on appeal.
How does New York define “Fraud”?
Any person who knowingly and intending to defraud the workers’ compensation system by presenting (or assisting in presenting) an application for benefits, which contains a misrepresentation of a material fact. The penalty: Class E Felony charges. In addition to a Class E Felony conviction, the claimant who is convicted loses the right to all past and future compensation benefits. Fraudsters have to return any money they got through their fraud. WCL § 114. This is contrary to the general rule of law that claimants do not have to pay back money fraudulently obtained.
A claimant who applies for workers’ compensation benefits is required to provide accurate records and truthful statements to the WCB, the insurance carrier, and the employer. However, the law does not require the claimant to give a truthful account of their condition to their medical care provider. The prohibition on false representations appears to only apply to false statements made to get a monetary benefit – it does not appear to apply to medical awards or benefits, since the prohibition on lying applies only to WCL § 15 (indemnity awards) and not expressly to § 13 (medical benefits) or § 16 (death benefits).
An employer has the right to report suspected workers’ compensation fraud to the Fraud Inspector General. However, fraud will actually be inspected by the office of the Workers’ Compensation Fraud Inspector General which is actually staffed by WCB employees. The Fraud Inspector does not prosecute cases – rather, it refers cases to local authorities for prosecution. Continue reading Explainer: Fraud as a Defense in New York Workers’ Compensation Claims.
The common image of workers’ compensation fraud most likely looks like this: An employee claims to be totally disabled and therefore cannot work at all yet he or she actively makes improvements to their homes, enjoys recreational sporting activities, engages in yard work, or perhaps takes glorious vacations, all while accepting healthy indemnity benefits for months at a time.
The above scenario may be true in some circumstances, but in truth, New York workers’ compensation fraud may take many forms and result in a myriad of consequences. New York Workers’ Compensation Law (WCL) section 114(a) governs fraud and describes significant penalties for those who are caught committing fraud such as a permanent ban on their eligibility to receive indemnity benefits and/or a permanency award. Continue reading New York State Workers’ Compensation Fraud: Stereotypes versus Reality.