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Workers’ Compensation: New Jersey Anti Fraud Provision and Injured Workers Prior Medical History

By: Attorney Jeffrey S. Monaghan

Over the past several years there has been an increased emphasis by defense attorneys representing workers’ compensation carriers in the defense of workers’ compensation claims for information regarding an injured workers prior medical history and a request for medical records of any doctor who had previously treated the injured worker, including the injured worker’s family doctor’s medical records. Workers’ Compensation Insurance Carriers, as part of their investigation of a work related claim routinely conduct a search that indicates information as to whether the injured worker has ever previously been involved in any types of accidents or lawsuits. When information is turned up in this investigation that proves to be different from the information initially provided by the injured worker, insurance carriers are contending that the injured worker has violated the anti fraud provision of the workers’ compensation statute.

The New Jersey anti fraud provision contained in N.J.S.A. 34:15-57.4 reads as follows.

If a person purposely or knowingly makes when making a claim for benefits pursuant to (the Workers’ Compensation Act) a false or misleading statement, representation or submission concerning any fact which is material to that claim for the purpose of obtaining the benefits, the Workers’ Compensation Division may order the immediate termination or denial of benefits with respect to that claim and a forfeiture of all rights of compensation or payments sought with respect to the claim. The anti fraud provision establishes a fourth degree crime for making a false or misleading statement, representation or submission concerning any fact that is material to the underlying claim for the purpose of wrongfully obtaining workers’ compensation benefits.

On March 14, 2014, the New Jersey Appellate Division in the case of Natalie Bellino v. Verizon Wireless rendered a decision, which among other things specifically considered and addressed the issue of what specific allegations must be established and proven in order for the anti fraud provision to apply.

In the Bellino case, the defense attorney representing the workers’ compensation insurance carrier charged that the injured worker had given inconsistent and inaccurate information regarding her prior medical history and prior use of medications to the doctors who had rendered treatment to her in aftermath of the work accident, as well as the doctors who had examined her for the purpose of estimating her overall permanent disability from the accident. Specifically, the defense attorney charged that the injured worker failed to acknowledge a prior workers’ compensation injury approximately 10 years prior to the current accident, involving similar injuries to the body parts being alleged in her current claim.

According to the defense, the conflicting and inaccurate information amounted to a “fraud” on the part of the injured worker and in order to receive a workers’ compensation award by intentionally making false and misleading statements. 

After a full Trial, before a Workers’ Compensation Judge, the Trial Judge rejected the fraud defenses raised by the insurance carrier and found the injured worker entitled to workers’ compensation benefits. The Trial Judge indicated in his decision that he had found the overall testimony of the injured worker credible, honest and straightforward.

The workers’ compensation insurance carrier took an appeal to the New Jersey Appellate Division and among the issues raised on the appeal, the defense contended the Trial Judge should have denied and dismissed the workers’ compensation claim due to the specific violations of the anti fraud provision of the statute. 

The Appellate Division in affirming the Trial Judge’s decision, found that the anti fraud provision of the statute is intended to rule out fraudulent and improper claims and is not intended to test an injured workers ability to remember every detail of perhaps a lengthy complicated past medical history, or to accurately determine what information may be material for the purposes of receiving treatment or other workers’ compensation benefits.   The Appellate Division held that all elements of the anti fraud division must be proven by competent evidence in order for a defendant’s Motion to Dismiss a claim based on violation the anti fraud provision to prevail.

Notwithstanding the decision of the Appellate Division in Bellino case, which sets forth specific elements which must be clearly established and proven by a defense carrier in asserting a claim that an injured worker has violated the anti fraud statute, it can be expected that defense insurance carriers will continue their practice of attempting to raise fraud charges when incomplete or inaccurate information is provided by an injured worker concerning their past medical history. 

For the most part, an individual’s past medical history unrelated to the specific injuries being alleged in the pending workers’ compensation case has little or no relevancy to their case at hand and such information need not be turned over the to the defense in connection with their defense of the pending case. Nevertheless, to avoid repeated delays in the prosecution of their case, and avoid fraud charges being alleged against them by the insurance carrier, it is incumbent on an injured worker to be as detailed and accurate as possible in explaining their complete past medical history to the attorney who is representing them in the pending claim.   The claimant’s attorney can then make an accurate assessment as to what if any information regarding a worker’s past medical history is relevant to the case at hand and should be shared with the defense attorney.

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