A recent trend in New York State Workers’ Compensation claims defense involves insurance carriers alleging fraud because patients allegedly misrepresent their symptoms and abilities at the time of examination.

When a Workers’ Compensation claimant treats with his doctor and complains that he or she is in debilitating pain all day, everyday, and that they are not able to do any of their daily activities including driving or fixing breakfast, a medical report will be generated and submitted to the Workers’ Compensation insurance carrier.

The insurance carrier reviews the report received from the doctor’s office. The adjuster, already skeptical of the claimant, finds it difficult to believe the severity of the symptoms complained of and restrictions noted. The insurance carrier contacts a private investigator who follows the claimant for a few days and secures video of the claimant driving his or her vehicle to the post office, grocery store, and/or gas station buying and carrying groceries or pumping gas in no apparent pain or discomfort.

This is enough for the insurance carrier to allege a violation of Section 114a fraud. The allegation is that the claimant made material misrepresentations of fact, namely that their pain was so severe that they were unable to perform any daily activities. If that misrepresentation was made for the purpose of receiving ongoing Workers’ Compensation benefits that they would otherwise not be entitled to then the Law Judge could find a violation of fraud.

The moral of the story is to accurately convey your symptoms and restrictions to your physician and not to embellish or exaggerate them.