Lois Law Firm Proves Claimant’s Fraud

Lois Law Firm’s Construction Defense Team successfully obtained a fraud ruling (“114-a finding”) favorable to the employer due to the claimant’s concealment of prior medical treatment. The Court ruled that the claimant had committed fraud and imposed a penalty of no further indemnity benefits as a result.

This claim was established for the right shoulder, right calf, right elbow, neck, left shoulder, right wrist, and lower back. In his C-3 dated February 25, 2019, the claimant alleged that when he was taking equipment downstairs, he tripped over a garbage bag that was left on the stairs and fell down the stairs. The claimant testified that he was only ever involved in one motor vehicle accident involving a parked car. However, through thorough investigation, records were discovered for an accident where the claimant was struck by a reversing vehicle while crossing the street.  It was also discovered that the claimant underwent comprehensive treatment in connection with this prior claim. However, he failed to disclose it when he testified in this claim.

After extensive development of the record utilizing these prior records, cross-examination of the claimant, and arguments made by LOIS that the claimant made a material misrepresentation by failing to disclose this prior accident and treatment, the Law Judge found fraud under WCL Section 114-A.  The Law Judge reasoned that the claimant did not reveal prior treatment when asked about it under oath or to any treating or IME physician, and this is material as the treatment involved body parts that were allegedly injured in the instant claim.

This finding of fraud was a tremendous cost-savings win for the client, as it curbed indemnity exposure in a claim that could have potentially ended with a high LWEC finding.  

In addition, in this same case, the Law Judge imposed an excessive $1,000 penalty against the Carrier for alleged duplicative C-8.1Bs that had been submitted to the file. LOIS appealed this decision and argued to the Board Panel that these denied treatment bills were not duplicative as the Carrier was billed for the same dates of service over and over, and was protecting its rights under 12 NYCRR 325-1.25. Upon review of the record, the Board unanimously found the penalty imposed was not appropriate and modified the Law Judge’s Decision to rescind the WCL Section 114-a(3)(i) penalty in the amount of $1,000.00 against the carrier.