The Louisiana Third Circuit Court of Appeal recently addressed the issue of fraudulent conduct concerning workers’ compensation claims of injuries and treatment. In this case, the appellate court affirmed summary judgment in favor of the employer, on the grounds that the employee violated a Louisiana law making it unlawful to willfully make false statements or representations for the purpose of obtaining benefits or payment.
Here, the plaintiff, Mark Edwards, worked as a driver for Southeastern Freight Lines, Inc. and allegedly suffered injuries to his legs and his back while unloading a cylinder or steel beam. After calling his employer, he completed the majority of his daily deliveries. The next day, he went to the hospital and received a diagnosis of lumbago (disc degeneration affecting the lumbar spine) and a lumbar region strain. He denied prior problems with his back, and his employer began paying indemnity benefits because Mr. Edwards did not return to work.
Almost one week later, Mr. Edwards went to another doctor who diagnosed lumbago. Mr. Edwards denied having had previous back problems. The next morning, an adjuster telephoned Mr. Edwards and recorded his statement concerning his injuries. When asked if he had suffered former job-related injuries, automobile accident injuries, or back problems. Mr. Edwards stated he had not suffered any of these injuries.
Weeks later, the adjuster received information showing previous work-related auto accidents and injuries and information about hospital treatment, the day before the accident. Mr. Edwards’ benefits were temporarily terminated, and he filed the first of three 1008 claims.
Southeastern Freight Lines, Inc. permanently terminated Mr. Edwards’ benefits. They filed a motion for summary judgment and sought forfeiture of benefits based on Mr. Edwards’ misrepresentations made for the purpose of obtaining workers’ compensation benefits. Mr. Edwards argued it was error for the trial court to grant summary judgment in favor of his employer.
The appellate court stated that on review, a motion for summary judgment is reviewed using the same criteria that governed the trial court’s determination of whether the motion was appropriate.
Turning to the statute at issue, Section 1208(A) or La.R.S. 23:1208, the court stated that the requirements include a false statement or representation, willfully made, for the purpose of obtaining workers’ compensation benefits. This statute applies if the false statements were made regarding prior injuries, and it also applies to statements made to insurance investigators as well as physicians.
The court stated the policy implication of allowing for forfeiture of benefits. A false statement must be willfully made in order to obtain benefits. This requirement, the relationship between the statement and the pending claim, determines whether the statement was made in order to obtain benefits, as opposed to an inconsequential false statement that would not result in the forfeiture of benefits.
In assessing the willful and repeated misrepresentations made by Mr. Edwards, the court first analyzed the recorded statement with the adjuster, noting that Mr. Edwards denied previous back problems and any medical conditions. Next, Mr. Edwards’ responses to interrogatories listed minor injuries from two automobile accidents that were not work-related. The adjuster also testified by deposition that she received search results indicating Mr. Edwards sustained work-related injuries when working as a bus driver. He received workers’ compensation for six weeks and settled a claim against a driver for $8,000.00. The search results also revealed a personal automobile accident and two commercial automobile accidents.
Finally, the day before the accident at issue, Mr. Edwards’ records reveal that he was treated as a walk-in at Alexandra VA Health Care System with complaints of back pain. According to the appellate court, Mr. Edwards made numerous false and relevant assertions, continuing to deny all work-related injuries. In addition to false statements and denials of previous injuries, the court stated that Mr. Edwards denied events to physicians treating him for the accident at issue.
The court stated that Mr. Edwards repeatedly and willfully made false statements about his medical history, after the accident, for the purpose of receiving workers’ compensation benefits. Here, Mr. Edwards argued that he lacked willful intent, and summary judgment therefore should not be granted. But the court stated that since Mr. Edwards made the false statements after reporting a job-related injury to his employer, they were made for the purpose of obtaining workers’ compensation benefits.
The court also stated that Mr. Edwards’ assertion that his failure to list back injuries is because they were normal and not significant does not create a genuine issue of material fact to be resolved at trial. Here, reasonable people would find that Mr. Edwards willfully made false statements in order to obtain workers’ compensation benefits. The court affirmed the grant of summary judgment.
At Lavis Law, we help our clients navigate the workers’ compensation process, representing injured employees. We provide a free consultation and can be reached by calling 866. 558.9151.
More Blog Posts:
Louisiana Appeals Court Rules in Favor of Injured Employee and Finds No Fraud in Her Injury Claims, Louisiana Job Injury Law Blog, August 21, 2015
Louisiana Appeals Court Affirms that Plaintiff is Borrowed Employee Barred from Pursuing Tort Claim, Louisiana Job Injury Law Blog, August 14, 2015