Court of Appeal Discusses Fraud and Forfeiture in Hammond Employee’s Workers’ Compensation Claim

money-man-3-1190250When an employee is injured on the job, he or she may be entitled to workers’ compensation benefits. However, if an employer can show that the employee intentionally lied to receive extra reimbursement for a workers’ compensation claim, the employer will not have to pay any benefits that it would otherwise owe to that employee. A recent case out of Hammond, Louisiana, discusses the standard used in determining whether an employee intentionally committed fraud when filing for mileage reimbursements.

In September 2011, an employee of Sanderson Farms (SF) was injured during a work-related accident. SF paid the employee indemnity benefits following the accident. But in December 2011, it terminated those benefits before the employee was scheduled to return to work. After returning to work, the employee continued to work for Sanderson Farms for another month. Then, in May 2012, the employee filed a claim against Sanderson Farms seeking to recover workers’ compensation benefits for the injury he sustained while on the job. Sanderson Farms denied the employee had a present work-related disability and maintained that the employee was not entitled to further indemnity benefits or medical treatment. Sanderson Farms also raised the affirmative defense of fraud, claiming the employee forfeited his right to all benefits when he submitted mileage reimbursement in excess of the actual distance he traveled in visiting various healthcare providers.

The Office of Worker’s Compensation held a three-day trial focusing on SFs’ fraud defense. In support of the fraud allegation, Sanderson Farms sought to prove that the employee lied about the amount of miles he traveled to and from the 15 doctors’ appointments he attended from September 2011 to November 2011. It is unlawful for an employee to willfully make a false statement or representation for the purpose of obtaining any worker’s compensation benefits. An employee violating this law forfeits any right to workers’ compensation benefits. The forfeiture statute must be strictly construed because forfeiture of benefits is a harsh remedy. See Our Lady of the Lake Regional Medical Center v. Mire, 142 So.3d 52 (La. Ct. App. 2014). As such, if an employer fails to prove even one element of the forfeiture statute, it will not be able to avoid liability in a workers’ compensation claim. Here, in order for SF to prove its fraud allegation it had to demonstrate that the employee willfully lied about where he was living and the distance he traveled to and from his medical appointments in an attempt to receive more money for mileage reimbursement than he was due.

The Workers’ Compensation Judge (“WCJ”) was not persuaded by the evidence of fraud put forward by SF. The WCJ ruled in favor of the employee and required Sanderson Farms to pay disability benefits. The WCJ concluded that the employee did not intentionally provide fraudulent information. The employee relied on the nurse case manager at Sanderson Farms and the adjustor handling his claim to guide him through the workers’ compensation process, which included the mileage reimbursement process. Despite the adjustor’s denial that she spoke with the employee regarding the mileage issue, the WCJ concluded that the employee tried to get help with the mileage reimbursement and the adjustor should have spoken with the employee about his place of residence in submitting the reimbursement request.

On appeal, SF again argued that the employee had committed fraud by intentionally submitting mileage reimbursement requests that overstated the distance he traveled to and from doctors’ appointments. It furthered argued that the employee perpetuated and exacerbated this fraudulent act by offering false testimony at trial about where he was living at the time.

Whether the employee’s allegedly false statement constitutes a forfeiture of worker’s compensation benefits is one of fact. A lower court’s finding of fact may not be disturbed on appeal unless there is no reasonable factual basis for the finding. In reviewing a lower court’s decision, the issue to be resolved by the Court of Appeal is whether the court’s conclusion was a reasonable one. See Stobart v. State, Department of Transportation and Development, 617 So.2d 880 (La. 1993). Where, as here, the WCJ’s factual determination is based on a credibility determination, great deference is given to the trier of fact’s findings. This is because the lower court is better placed to analyze a witness’s credibility having observed the witness’s narration, body language, and tone.

In this case, the Court of Appeal affirmed the WCJ’s ruling. It reviewed the trial record and found that the WCJ thoroughly assessed the employee’s credibility and clearly articulated her reasoning based on the evidence presented. It thus affirmed the WCJ’s finding that the employee did not intentionally defraud the workers’ compensation system.

Even if you win your workers’ compensation claim, the employer may have another shot to defeat your claim on appeal. Here, the employer attempted to establish that the employee fraudulently represented the mileage on his reimbursement claim. Yet good trial work overcame the employer’s appeal. A good lawyer will help you navigate every route to recovery and vigorously defend your award on appeal.


Additional Berniard Law Firm Articles on Workers Compensation and Possible Fraud: Burger King Employee Loses Out On Workers’ Compensation After Misrepresenting Injuries

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