Greetings,

The Division of WC and the Division of Insurance Fraud just issued their annual joint report.  Remember, there are two avenues for pursuing WC fraud, the JCC through the WC system and the criminal system through the DIF.  Some interesting facts of claims reported to the DIF:

• 17,300 referrals of suspected fraud last fiscal year (July 2014-June 2015)

• 1,318 arrests, which led to 1,195 successful prosecutions

These were not all claimants, some were employers,  Its is mandatory that you report any cases of suspected fraud to the DIF.  Here’s a link to the entire report.

http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Reports/DIF-DWC-Joint-Annual-Report-2014-2015.pdf

The JCC avenue for fraud/misrepresentation is under 440.105.   The pertinent sections read:

(4) (b) It shall be unlawful for any person:

1. To knowingly make, or cause to be made, any false, fraudulent, or misleading oral or written statement for the purpose of obtaining or denying any benefit or payment under this chapter.

2. To present or cause to be presented any written or oral statement as part of, or in support of, a claim for payment or other benefit pursuant to any provision of this chapter, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such claim.

3. To prepare or cause to be prepared any written or oral statement that is intended to be presented to any employer, insurance company, or self-insured program in connection with, or in support of, any claim for payment or other benefit pursuant to any provision of this chapter, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such claim.

4. To knowingly assist, conspire with, or urge any person to engage in activity prohibited by this section.

5. To knowingly make any false, fraudulent, or misleading oral or written statement, or to knowingly omit or conceal material information, required by s. 440.185 or s. 440.381, for the purpose of obtaining workers’ compensation coverage or for the purpose of avoiding, delaying, or diminishing the amount of payment of any workers’ compensation premiums.

6. To knowingly misrepresent or conceal payroll, classification of workers, or information regarding an employer’s loss history which would be material to the computation and application of an experience rating modification factor for the purpose of avoiding or diminishing the amount of payment of any workers’ compensation premiums.

7. To knowingly present or cause to be presented any false, fraudulent, or misleading oral or written statement to any person as evidence of compliance with s. 440.38, as evidence of eligibility for a certificate of exemption under s. 440.05.

8. To knowingly violate a stop-work order issued by the department pursuant to s. 440.107.

9. To knowingly present or cause to be presented any false, fraudulent, or misleading oral or written statement to any person as evidence of identity for the purpose of obtaining employment or filing or supporting a claim for workers’ compensation benefits.

It is an affirmative defense, and we must prove the claimant “knowingly” acted in such a manner.   How do you prove that?   By their actions, such as telling you the truth in a recorded statement and then lying.  Surveillance can be used for misrep, if a doctor testifies the claimant lied about his abilities.  As many of you have seen, these can be tough to prove, but typically the more instances you have of the misrep in the case the better. 

Don’t pull the trigger too soon on a denial, talk to your defense attorney first.
Morgan Indek | Partner