In Louisiana, a Claimant who willfully and deliberately makes false statements for the purpose of obtaining workers’ compensation benefits will create a bar to his workers’ compensation claim, and possibly be subject criminal charges. Louisiana’s “fraud defense” is codified in Louisiana Revised Statute 23:1208.
The recent decision by the Third Circuit Court of Appeal of Louisiana in Wood Group PSN, Inc. v. Romero illustrates the interplay of the “fraud defense” in Louisiana workers compensation proceedings when a Claimant misrepresents medical history to treating medical providers.
In February 2013, the Romero claimant was employed as an operator, maintaining satellite oil well platforms in Black Bay, Louisiana. The claimant was being transported from headquarters to a well by a crew boat. During the transfer from the crew boat to the platform, claimant allegedly twisted his ankle. Claimant maintained that he had to be assisted back to the crew boat, and later to headquarters.
On the day of the work accident, Claimant sought medical treatment and was diagnosed with a sprained ankle. In July 2013, he underwent an arthroscopy of his left ankle, and eventually underwent fusion surgery in November 2013.
However, it was discovered by his employer that, in 2006 (years prior to the alleged work accident at issue), Claimant had injured his left ankle while in the course and scope of his employment with a different employer. An MRI performed following this prior incident revealed a torn ligament, for which claimant underwent a lateral ligament tear and ankle reconstruction. For the 2006 work accident, claimant received workers compensation benefits and was out of work for approximately seven months.
The evidence was undisputed that Claimant failed to disclose his prior work-related ankle surgery to any of his medical providers for the work accident at issue. He also failed to disclose the prior condition to his current employer when he sought employment.
After learning of these developments, employer filed a 1008 Disputed Claim, alleging that claimant violated La.R.S. 23:1208 by intentionally misrepresenting his medical condition by failing to disclose the prior ankle injury and resulting surgery. The WCJ rendered judgment in employer’s favor, and ordered that claimant forfeited his entitlement to benefits. The WCJ declined to award restitution or assess a civil fine. Claimant appealed.
Relying on the Louisiana Supreme Court’s decision in Resweber v. Haroil Constr. Co., 94-2708 (La. 9/5/1995); 660 So. 2d 7, 16, the Third Circuit affirmed the WCJ’s ruling. The appellate court noted that “false representations must be made for the purpose of obtaining benefits, and must be more than inadvertent or inconsequential statements.” Claimant argued on appeal that his misrepresentations were not made for the purpose of obtaining any benefit or payment. The appellate court dismissed claimant’s argument, agreeing with the WCJ’s determination that “there is a very strong relationship between the failure to disclose the prior left ankle surgery and the pending claim for treatment and disability due to the left ankle.”