Claimant, Not Employer, Committed Fraud

The issue of fraud, prevalent in the workers’ compensation arena, once again reared its head in a case before the Third Circuit Court of Appeal of Louisiana.  Claimant was employed as a cook for Employer, and fainted in the course and scope of her employment.  It was thought that she had a stroke, and she was immediately sent to the hospital via ambulance.  After receiving medical attention, a stroke was ruled out, but it was determined that Claimant tore a tendon in her shoulder.  Claimant filed a claim for benefits, and Employer raised the fraud defense.  After a trial, the workers’ compensation judge found that although Claimant sustained a compensable injury, she had forfeited her entitlement to the corresponding workers’ compensation benefits due to fraud.

Claimant appealed the judge’s ruling, and raised two assignments of error.  Claimant argued that the judge erred in finding that forfeiture was allowed, and also erred in finding that Claimant failed to prove her allegations that Employer committed fraud.  Claimant maintained that misstatements regarding her prior medical history were due to confusion rather than intentional deceit, and that Employer withheld evidence from the workers’ compensation insurer in an effort to deny her benefits.

The appellate court reviewed the record to determine whether the workers’ compensation judge’s findings contained manifest error.  Claimant indicated in her post-hire medical form that she had no history of shoulder pain or problems.  She also claimed she never missed work due to injury, never had problems lifting, and was never limited by a doctor from working prior to being employed by Employer.  The record, however, demonstrated that Claimant complained of shoulder pain to multiple providers dating back to 2006.  Claimant also sustained a previous work related shoulder injury with a prior employer that caused her to have difficulty lifting.  The appellate court found that in light of these numerous contradictions, it was not possible to find manifest error in the workers’ compensation judge’s findings.

The appellate court also affirmed the workers’ compensation judge’s finding that Employer did not commit fraud.  Claimant alleged that Employer knowingly withheld information from the workers’ compensation insurer to prevent her from receiving benefits, but the appellate court’s findings mirrored those of the workers’ compensation judge – the record was completely devoid of evidence supporting fraud on the part of Employer.  Employer believed that Claimant had suffered a non-work related stroke, which is why the injury was not reported to the carrier.  Further, Employer had no knowledge of the allegations of a shoulder injury until it was contacted by Claimant’s counsel.

The decision to impose or deny forfeiture is a factual finding that the appellate court will not disturb absent manifest error.  Here, although Claimant felt that the evidence was improperly weighed by the workers’ compensation judge, the issue to be resolved was not whether the trier of fact was right or wrong, but whether the conclusion was reasonable.

Bartley v. Garden View Assisted Living