N.J.S.A. 34:15-57.4, commonly known as the New Jersey Workers’ Compensation Fraud Statute, is paraphrased below as it relates to an injured worker making a claim for benefits.
A person shall:
(a) Be guilty of a crime of the fourth degree if the person knowingly or purposely:
When making a claim for Workers’ Compensation benefits, makes a false or misleading statement, representation or submission concerning any material fact;
(b) Any person who violates the above shall be civilly liable to any person injured by the above violation.
(c) (1) If a person knowingly or purposely violates this statute the Workers’ Compensation Division may order immediate termination or denial of benefits, and forfeiture of any future benefits/rights.
(2) If a violation is found, the person has to pay back the benefits received plus simple interest.
(d) Nothing in this section shall preclude indictment and conviction for a violation of Title 2C of the NJ Statutes.
For example, an injured worker makes a claim for treatment for a cervical spine injury that happened at work in 2012. The Employer’s attorney discovered a prior cervical MRI from 2002 that showed a C5- 6 disc herniation and used that to stop paying benefits, and filed a counter- motion to relieve the employer of any responsibility under the above Fraud Statute. The injured worker told all treating physicians that he had a prior 2002 biking injury, however he stated to all physicians, that the prior injury was to his right shoulder. He did not reveal the fact that he had a cervical MRI in 2002 to any current physician. He also did not recall being told by any prior physicians that he had any significant cervical injury, and felt that he had only injured his right shoulder in the 2002 biking accident.
The issue is whether the workers’s failure to reveal the prior 2002 cervical MRI to the treating physicians for his 2012 injury was a knowingly or purposely made false or misleading statement to obtain workers compensation benefits. I would argue that the failure to reveal the prior MRI was not fraudulent in any way. Dr Grey, the treating doctor from the 2012 accident states in his report the he spoke with him (the worker) about the previous cervical MRI findings, and he was surprised to learn that he had experienced a previous disc herniation at the same level where he was operated on. He is adamant that his prior treating doctor in 2002 never advised him of any neck concerns, and there is no reason in any of the records which I have been provided to disbelieve the patient in that regard.”
It is clear that the injured worker told all treating doctors about his prior 2002 shoulder injury. He did not specifically mention a cervical injury because in his mind he injured and had surgery to his right shoulder, not his neck. It is reasonable to assume that 10 years after a prior injury, a worker would not remember he had a cervical MRI, when he did not get any treatment for his neck and had no complaints for his neck. It is also likely the Employer would never be able to prove that this worker made a false or misleading statement because the standard of proof for 34:15-57.4 (a), which involves a crime of the fourth degree, requires proof beyond a reasonable doubt. That type of proof would never be possible in this case.
Please call Stark and Stark’s workers’ compensation department for all of your workers’ compensation questions.