Worker’s compensation fraud doesn’t get the credit it deserves by my fellow prosecutors. The general public, on the other hand, eats these cases up. My opinion is that the public knows that those are are defrauding the system in this way are harming everyone: insurance premiums rise meaning the costs of goods and services also rise to pay for the difference. Also, these cases tend to involve the use of sub-rosa video surveillance by private investigators hired by insurance companies who follow fraudsters around and catch them in their lies. Who doesn’t love a good “gotcha” moment?
#15 involved a former private security officer who was ultimately convicted of five separate counts of Workers Compensation fraud. Essentially the defendant claimed that as he was putting gas in his work vehicle another vehicle backed into his own causing him to be knocked down. Defendant claimed extensive back, neck and leg pain as a result of this accident and went to seek medical treatment.
In a follow up visit, the defendant changed his story and told doctors that his vehicle “spun around,” knocking him to the ground. Later investigators were able to retrieve a copy of a surveillance tape from the gas station which showed the impact to be minor, revealed the defendant was never knocked down, and showed the defendant walking normally after the impact, but then started limping when the other party involved in the bumper tap saw him. When that individual left, defendant started walking normally again.
Defendant was seen by a variety of doctors during the course of his treatment under his employer’s workers’ compensation insurance and he repeatedly denied any back, neck or leg injuries prior to this. However, investigation later determined he had in fact suffered the same type of back injury he was now claiming when he had been lifting boxes 10 years prior. This prior injury had also been treated under the worker’s compensation system. Defendant had also complained to several co-workers about back pain and was taking pain medication for his back approximately one month prior to the incident. He had not disclosed the prior back injury to his employee at the time of hire. He also failed to report this prior injury to doctors treating the current injury.
Therein lied the fraud. Defendant was required to truthfully report prior injuries to his worker’s compensation doctors so they could make accurate determinations regarding treatment as well as assess what injury was attributable to which event.
The case was further compounded by the extended treatment defendant received. His hesitancy to either return to work or to accept re-training under the worker’s compensation also did not help his case. Lastly, undercover surveillance tapes of the defendant showed the defendant using a cane to enter the doctor’s office, but not on other occasions. He was also filmed lifting bails of hay to feed his horses and lifting 4-5 gallons of milk at a time at the grocery store.
For this case, the validity of the injury actually wasn’t the issue. Back injuries are tricky beasts in the medical world. It is very hard to say when the event happens that causes the problem. I didn’t have to prove the validity of the injury itself though. The issue was whether or not the misrepresentations relating to the prior injury were material in the doctors determinations in the worker’s compensation system and whether or not those misrepresentations resulted in the defendant receiving a benefit he would not have otherwise received.
The sheer volume of information available in this case was a learning experience for me. I had three years worth of medical records from five doctors who ultimately testified. We had video surveillance, co-worker testimony, as well as employment records and prior worker’s compensation claim records. ALL of that information was brought into court. It was not all admitted into evidence-defense counsel and I worked hard to stipulate down the records into packets that were manageable for the jury. However, with a paper case, the magnitude of the information available is sometimes evidence in and of itself.
I can remember a very specific moment when defense counsel was attacking the medical records from one of the doctors. I was able to find the information I needed in the stacks of records, have my investigator copy it, and then mark it as an exhibit in front of the jury. It was only by having a full understanding of all the evidence available to me that I was able to overcome that entire line of questioning by defense. This trial taught me that mastering of all the evidence is essential in jury trials whether or not you intend to use it in your own case-in-chief.
This caught-on-camera fraudster didn’t get away with it. Ultimately he was convicted and was ordered to repay all of the money and benefits he received during the three year period he received care under the worker’s compensation system. Further hearings, after the jury trial, occurred to determine what defendant owed. Ultimately, the worker’s compensation company settled with the defendant to help alleviate the hundreds of thousands of dollars of potential debt he accumulated by the lies he told.