Congratulations to Karen Darling on securing an outstanding Workers’ Compensation fraud victory for our client.
In this case, the claimant repeatedly represented to the carrier, medical providers, IME physicians, and even his own counsel that he was not working following his alleged injury. Through a thorough investigation and strategic litigation, Karen established that the claimant had, in fact, been actively employed by a second employer for months—including working overtime—while simultaneously collecting workers’ compensation indemnity benefits.
The evidence ultimately revealed a significant discrepancy between what the claimant reported and what was actually occurring. By obtaining payroll records, employment documentation, medical records, and testimony that contradicted the claimant’s assertions, Karen successfully demonstrated a violation of Workers’ Compensation Law §114-a. as a result, the claimant was retroactively found not entitled to benefits from the inception of the claim forward with a mandatory penalty imposed amounting to $9,472.84” and was permanently disqualified from receiving future indemnity benefits related to the claim.
A key factor in this success was the claims investigation conducted at the inception of the file. The claims professional took the time to interview the claimant and document statements concerning work status and outside employment. Detailed claim notes were maintained and preserved, creating contemporaneous evidence that later proved invaluable when the claimant’s testimony changed.
This case serves as an important reminder to carriers, self-insured employers, and third-party administrators that fraud investigations often begin long before litigation. Claim professionals should always conduct thorough claimant interviews at the outset of the claim and ask detailed questions regarding all current and prior employment, side jobs, self-employment activities, and sources of income. Answers should be carefully documented. When appropriate, subpoenas should be issued to obtain records directly from potential employers.
Too often, opportunities to establish fraud are lost because critical questions were never asked or because the claimant’s representations were not adequately documented. Here, the detailed claim notes, coupled with strategic discovery directed to the second employer, created a compelling evidentiary record that exposed the claimant’s misrepresentations.
Congratulations to Karen on an exceptional result and for demonstrating how careful claims handling, meticulous documentation, and aggressive investigation can protect clients from fraudulent claims.
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