Fraud or Misrepresentation and Workers’ Compensation

Boca Raton Workers Compensation Lawyer

In Florida, the burden is on injured workers to prove that they suffered a workplace accident.  For all injuries, an injured worker needs to prove disability by a reasonable degree of medical certainty based on objective relevant medical findings; and also that the accident is the “major contributing cause” of any resulting injuries.  (Fl. St. 440.09(1)).  Major contributing cause means that the accident caused more than 50% of the resulting disability and need for treatment.  Objective findings are those beyond just the subjective complaints of pain or other symptoms coming from an injured worker. There must be medical findings on physical examination or diagnostic tests to confirm any complaints.

Workers’ Compensation Benefits

Workers’ compensation benefits generally fall into one of two categories. Benefits are either for lost or reduced wages, referred to as “indemnity” benefits; or are for medical benefits which include treatment, prescriptions, apparatuses, and mileage reimbursement among other things. Yes, you read this correctly, there is compensation for pain and suffering or emotional distress or punitive damages to punish the employer for causing or creating the circumstances leading to your injury.  It does not matter that you have been seriously injured and may not ever be able to return to the same line of work that you used to do or be able to go back to doing the activities you enjoyed doing before the injury.

This is because workers’ compensation in Florida is a no-fault system. The benefit of this system is that an injured worker does not have to prove that he or she did not cause or contribute to the accident.  It does not even matter if the injured worker caused the accident.  The employer must pay benefits regardless of fault.  But, in exchange for this, employers are not liable for pain and suffering and other forms of awards available under tort. Employers only have to pay benefits for lost wages and medical care.

Pre-Employment Questionnaire 

Many employers require employees to complete pre-employment questionnaires prior to or at the start of employment.  These questionnaires usually ask if the employee had any prior conditions and present a laundry list of medical conditions.  In addition, these questionnaires ask about prior accidents or injuries and list various parts of the body.  The employee is expected to check off yes or no to each body part of condition, and directly answer questions as to prior injuries.

Misstatements on Questionnaires  

Unfortunately, many employees are just focused on obtaining the job and do not really focus on these questionnaires or take them seriously.  They do not understand how these questionnaires can come to haunt them in the future, in the event that they get injured at the job.

Oftentimes, they will check off “no” to prior injuries and conditions because they feel that it was something minor and not a big deal, or far in the past.  Especially, if they feel they have made a full recovery and are no longer suffering from such injury or condition.

The problem is that employers can use these questionnaires after a work-related accident to get out of liability.  Employers can and do raise fraud or misrepresentation based upon these questionnaires.  Oftentimes, even if the injured worker explains that he or she thought the question was asking about their current disability or did not understand the question; Judges do not accept this explanation.

The Law

The workers’ compensation law specifically says that if an employee seeking employment falsely represents herself or himself in writing as not having previously been disabled or compensated because of such previous disability, impairment, anomaly, or disease; and the employer detrimentally relies on the misrepresentation, then benefits will be denied.  Fl. St. 440.15(5).

The Case

In addition to the statute, there is case law outlining what an employer needs to prove to win on fraud.  In the most well-known case, an injured worker answered “no” to a question on a pre-employment questionnaire asking if she ever had a prior back injury or backache.  In fact, she had experienced back pain for 20 years prior to her employment. After getting hired and working for the employer for 7 months, she experienced increased back pain and went out of work due to her back condition which had been aggravated by the standing and bending she had to do on the job.  She filed a workers’ compensation claim against the employer due to her back condition worsening.

The Court stated that in order for fraud to be satisfied, the employer must show 1) a causal relationship between the injury and the false representation and (2) that the employee knew the representation to be false, (3) the employer relied upon the false representation and (4) such reliance resulted in consequent injury to the employer.

The reason that the Court set forth these criteria is because an employer should have the opportunity to decide whether or not it wants to take on the risk of hiring an employee with a pre-existing condition.  It is more likely that a person with a pre-existing condition will have a greater risk of experiencing a re-injury or aggravation than a person with no prior conditions.  Thus, it should be up to an employer to weigh the risks of whether to hire a particular employee having this information and being able to make an informed hiring decision.  But, if an employee does not inform the potential employer of a pre-existing condition; the employer is being denied its ability to make that choice.

Causal Relationship Between Injury and False Representation

A causal relationship is shown by evidence of a “medical relationship” between the workplace injury at issue and the prior injury or condition, or by evidence that the prior injury or condition contributed to or was aggravated by the subsequent injury.  Thus, a prior shoulder condition would not be causally related to a work-related back injury.  If an employee failed to indicate on a pre-employment questionnaire that he or she had a prior shoulder condition and then suffered a back injury at work; there would be no causal relationship between the shoulder condition and back injury and arguably no fraud.

Reliance by Employer

In addition to the false statement of a prior condition that is related to the workplace accident, the employer must have relied upon the statement when hiring the employee.  For example, if the employer was a landscape company; the employer may say that the purpose of the questionnaire was to make sure that a new employee is not placed in a position, or asked to perform tasks, that may result in injury to himself or his coworkers. That, if the employer knew about the prior condition, it would not have hired the employee.

Fraud or misleading statements

In addition to pre-employment questionnaires which go to prior injuries or accidents; fraud can also apply whenever there is a misleading or false statement made in furtherance of a claim for workers’ compensation benefits. Section 440.105, F.S., makes it illegal for any person to knowingly make any false, fraudulent or misleading statement and Section 440.09(4)(a), F.S., denies benefits to the employee who knowingly or intentionally engages in any acts for the purpose of securing workers’ compensation benefits.  It is not necessary that a false, fraudulent, or misleading statement be material to the claim; it only must be made for the purpose of obtaining benefits.

This of course is not as straightforward as it seems and can lead to lengthy litigation.  The employer must prove that the statement was for the purpose of obtaining workers’ compensation benefits.  This often ends up with testimony from the injured worker explaining that he or she made the statement in question because he or she forgot, made a mistake, or left something out because he or she did not feel it was relevant or did not understand a question, rather than to mislead anyone in order to obtain benefits.

Intentional misleading statements

Fraud or misstatements can come in all shapes or forms.  It can be something an injured worker says to his or her treating physician.  For example, an injured worker may deny having been treated previously when asked by his or her doctor.  Or, may deny prior injuries or misrepresent the extent of his or her work injury, or the mechanism of injury. In all cases, the misstatement must be intentional.  The employer must prove that it was intentional, not a mistake or misstatement, AND was for the purpose of obtaining benefits.  This is not always an easy task.  But, if the employer can show an intentional statement was made for the purpose of obtaining benefits, then the claim will be denied.

In one case, the injured worker lied to his doctor about a prior back condition, but the work injury had to do with a knee injury. The prior back injury had nothing to do with the work-related back injury.  But, the Court found that it did not matter that these were two different body parts. Under, Section 440.105, Florida Statutes, it is illegal for any person to knowingly make any false statement for the purpose of obtaining workers’ compensation benefits.  It is not necessary that a false, fraudulent, or misleading statement be material to the claim; it only must be made for the purpose of obtaining benefits.  Accordingly, if the injured worker made any misrepresentation for the purpose of obtaining benefits, then he or she is barred from entitlement to benefits.

How to best prepare

As demonstrated in this article, if you suffer a work-related injury, your claim may already be in jeopardy.  You may not even remember filling out a pre-employment questionnaire.  But, it may and most likely will be brought up by the employer in defense of your workers’ compensation claim.  Having an attorney represent you through the complex workers’ compensation process will ensure that you are prepared in the event fraud or misrepresentation is raised against you.

Remember, if fraud is raised and proven successfully, your entire claim will be denied and all benefits will cease.  An employer can raise fraud at any time.  So, even if the employer starts paying you benefits following an injury; that does not guarantee that those benefits will continue.

It is important to explore these issues early on in a claim to ensure that you are best prepared to respond. The fraud defense tends to be the most surprising to most injured workers, especially in the context of pre-employment questionnaires.  Most injured workers fill out pre-employment questionnaires quickly, and or fill them out at the same time they are filling out a bunch of other pre-employment paperwork, and do not take those questionnaires seriously, or just do not take the time to read them. The focus of the employee at that point is just to get the job and fill out whatever paperwork they need to.  Most employees do not thoroughly read and understand everything that they are signing. They do not think there is any consequence to filling out the questions.

An experienced workers’ compensation attorney can help you navigate the system and ensure that you not only obtain the benefits that you are entitled to but help you maximize your benefits. Fraud is only one of many defenses that an employer may raise to try to get out of paying you benefits.  There are plenty of others such as major contributing causes, timely notice of the claim, and failure to return to work.  These are the subject of separate articles.

Bottom line, the workers’ compensation system is tough and not favorable to injured workers.  Employers and their defense attorneys will do what they can to deny your benefits.  If you have suffered a work-related injury, contact us at the LaBovick Law Group to see what benefits you may be entitled to and to have someone fighting for you.  We provide free consultations where we will review the facts of your case to determine the right course for you.  Call us today at (561) 625-8400 for your free evaluation.

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