Workers’ Compensation Claims: Fraud, Fraud & More Fraud

Rispoli & Borneo P.C.

Long Branch NJ Workers Compensation Lawyer – Long Branch NJ Work Injury Attorneys

 New Jersey workers compensation insurance companies and the attorneys that represent them are always yelling about fraud in the workers’ compensation system.  They consider every mistake and/or omission, in a medical record or doctor’s report, as evidence of fraud by the Petitioner.  When there are meticulous Long Branch NJ Work Injury Attorneys on both side of a case, there is no such thing as an innocent mistake.

Earlier this year, the New Jersey Appellate Division considered the issue of fraud in Bellino v. Verizon Wireless, 435 N.J. Super 85 (App. Div. 2014).  Specifically, the Court considered “the state of mind that a respondent must prove to disqualify a claimant who makes misstatements about his or her medical history when applying for benefits.” Id. at 753.

Whether or not one is a practicing NJ workers compensation lawyer, the facts of the case are fairly straight forward.  On February 23, 2010, Ms. Bellino tripped and fell while working for Verizon.  She began treating on March 2, 2010, at Concentra Medical Centers.  In April 2010, she was referred to Dr. Jonathan Lester who ultimately diagnosed her as suffering from Complex Regional Pain Syndrome (CRPS).  He recommended treatment including a series of nerve blocks.  Rather than accept the recommendation of the authorized treating physician, Respondent sent Ms. Bellino to Dr. Gallick for a second opinion.  Not surprisingly, Dr. Gallick concluded that she did not have CRPS, she did not need treatment and she could return to work full duty.  After securing the necessary reports, counsel for Ms. Bellino filed a Motion for Medical and Temporary Benefits, which was fully litigated.  At the end of testimony, the trial Judge granted the motion.

Respondent filed an appeal arguing among other things that Petitioner had committed fraud in violation of N.J.S.A. 34:15-57.4.  In support of this argument, Respondent pointed to a number of mistakes and omissions in Petitioner’s medical records and reports.  Ultimately, the Appellate Division upheld the Trial Courts decision.  In doing so, it specifically addressed the proofs necessary to establish fraud under the Workers’ Compensation Act.

In considering what it takes to support a finding of fraud, the Appellate Court pointed out that the anti-fraud provision of the Workers’ Compensation statute is a fourth-degree crime.  As such, it looked to the Criminal Code for guidance on what is required to establish that a petitioner “purposely and knowingly” made a false or misleading statement.  Id. at 757.  The Court concluded that “the fraudulent statement must be made with a conscious objective to obtain benefits to which one knows he or she is not entitled or with an awareness that the intentional falsehood will cause the desired result of fraudulently obtaining benefits.”  Id. at 757.  In other words, a simply mistake or omission is not enough.

Ultimately, the Court spelled out a three part test.  It found that to establish fraud “the moving party must show (1) the injured worker acted purposefully or knowingly in giving or withholding information with the intent that he or she receive benefits; (2) the worker knew that the statement or omission was material to obtaining the benefit; and (3) the statement or omission was made for the purpose of falsely obtaining benefits to which the worker was not entitled.”  Id. at 758.  Thus, it is not enough to simply establish mistakes and omissions in the medical records or reports.   More is clearly necessary to establish fraud under N.J.S.A. 34:15-57.4.

Will this opinion stop workers’ compensation insurance companies and their attorneys from alleging fraud at every opportunity? Probably not.  However, it does provide an experienced NJ workers compensation attorney with a definite three part test that the Respondent must meet to establish fraud and deny benefits.

Our attorneys are here to help. Contact a workers compensation attorney Northern New Jersey trusts from Rispoli & Borneo P.C. today for a free consultation.