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Explainer: Fraud as a Defense in New York Workers’ Compensation Claims.

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.

Greg LoisA 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.