Claimant Explains Away Misrepresentations to Defeat Fraud

The claimant sought benefits from his employer in connection with two accidents allegedly sustained in the course and scope of his employment. The employer defended the claims by arguing that the claimant’s injuries predated both accidents, and further argued that the second accident arose out of a possible opiate overdose.

The first accident allegedly occurred during a safety meeting when the claimant’s chair broke and caused him to fall and injure his spine. In the second accident, the claimant asserted that he slipped and fell on ice while loading his truck.

The employer argued that the claimant’s alleged injuries pre-existed both alleged accidents. In support of this assertion, it presented ten years of medical records predating the 2014 accident evidencing an extensive history of the claimant complaining of back and/or hip pain. According to the employer, “the records revealed the claimant saw a pain management doctor for ‘chronic and daily low back pain’ ‘nearly every month between March 2013 and the March 2014 work accident[,]’ and that notably, the claimant met with another pain management doctor the day before the 2014 accident and was sent home from work that day due to low back pain.”

As to the second accident, the employer argued that the accident resulted from an opiate overdose, not a slip-and-fall. The emergency room records for the slip and fall evidenced that opiate overdose was suspected as there was “no established cause albeit with suspicion of medication overdose as basis for present circumstance.” The records further showed that the claimant regained consciousness after being administered a reversal agent for opiates. The employer’s expert testified that the reversal agent “wont do anything” unless the person is suffering from an opiate overdose. Finally, the records indicated that his urine tested positive for opiates and that emergency medical services had reported a fresh needle mark to the left arm. None of the records indicated that he suffered from a head injury.

The employer filed a reconventional demand alleging that the claimant made false statements and misrepresentations in order to obtain benefits, and as such, the employer was entitled to restitution pursuant to La. Rev. Stat. 23:1208. Louisiana Revised Statute 23:1208 provides the following, in pertinent part:

A.  It shall be unlawful for any person, for the purpose of obtaining or defeating any benefit or payment under the provisions of this Chapter, either for himself or for any other person, to willfully make a false statement or representation.

E.  Any employee violating this Section shall, upon determination by workers’ compensation judge, forfeit any right to compensation benefits under this Chapter.

“To prove that a claimant committed fraud pursuant to La. R.S. 23:1208, the employer must prove that the claimant “(1) made a false statement or representation, (2) the false statement was willfully made, (3) and the false statement was made for the purpose of obtaining workers’ compensation benefits.” Gibson v. Resin Systems, Inc., 15-299, p. 8 (La.App. 3 Cir. 10/7/15), 175 So.3d 1141, 1147.” Although the record may evidence that the claimant made inconsistent statements or omissions about his prior medical history, not every false statement supports a finding of fraud.” Int’l Maint. Corp. v. Stoddard, 05-676, p. 2 (La.App. 3 Cir. 12/30/05), 918 So.2d 1077, 1079). Rather, the false statement or misrepresentation “must be made for the purpose of obtaining benefits.” Id.

Here, the Third Circuit acknowledged several obvious discrepancies between the claimant’s alleged work-related injuries and his medical records, but ultimately concluded that the claimant’s discrepancies were not made with the intent of obtaining benefits. The court was satisfied with the claimant’s explanation that he could not recall the events after the slip-and-fall. Additionally, the claimant testified that he was on Norco which is a medication that impacted his memory.

In essence, the medication at the root of the overdose allegation may have been the very reason the claimant was able to overcome allegations of fraud.

LeBouef v. RPC, Inc.