Denying Benefits When a Claimant Makes False, Fraudulent, or Misleading Statements
While it is always determined by the facts of each case, the First District Court of Appeal has just offered some additional guidance on determining whether a claimant has committed an act which will allow the JCC to determine that no further benefits are due to the injured worker. The decision is not yet final, but the First District Court of Appeal has issued a ruling this week clarifying misrepresentation defenses and providing direction as to what is required for a JCC to determine that a claimant has violated Florida Statute § 440.09(4) and 440.105. These statutes allow an Employer /Carrier / Servicing Agent to deny all further benefits in a workers’ compensation claim. In the case of Cal-Maine Foods / Broadspire v. Howard (CASE NO. 1D16-1789), the JCC found that a claimant had committed multiple misrepresentations, but they were moot and not made for the purpose of obtaining workers’ compensation benefits and therefore, declined to terminate benefits. The case involved a claimant that made numerous false statements regarding the surroundings of his accident, as well as his medical history, while receiving care for his compensable accident. The claimant also provided false statements about his accident and whether he had injuries to particular body parts during a sworn testimony. Prior to the Final Hearing, the claimant dismissed claims for body parts involved in which he had made false statements regarding the history of his accident, causation, and whether the injuries were related to the accident or some other non-work related reason. Even though claimant had admitted these statements were not true, all pending claims for payment of bills and provision of medical care to the affected body parts were dismissed prior to Final Hearing.
The First District Court of Appeal held that per Florida Statute § 440.09(4), the commission of any act of an employee prohibited under Florida Statute §440.105 results in the forfeiture of benefits.
To determine if there has been a violation of Florida Statute § 440.105(4)(b)a two prong inquiry is require:
1) A finding to whether a false, fraudulent, or misleading statement were made by the claimant; and
2) A finding as to whether (those statements) were made with the intent/purpose to receive workers’ compensation benefits.
The JCC had already determined that false statements were made in the Howardcase, satisfying prong one of the two prong inquiry. The JCC further found that even though the claimant had made false statements, they were not made for the purpose of obtaining workers’ compensation benefits – not satisfying the second prong under the statute. The First District Court of Appeal found the JCC misconstrued Florida Statute § 440.105(4) indicating subsection (4)(b) specifically sets forth those acts which are considered to be for “the purpose of securing workers’ compensation benefits.”
The First District Court of Appeal found that in Howard the JCC mistakenly ruled that the Employer / Carrier had to link the allegedly false or misleading statements directly to the injury for which benefits were sought. The First District Court of Appeal has previously ruled that is not required under the statute or corresponding case law. The following sentence in the Howard opinion: “[t]he parties have a right to expect that all statements, whether written or oral, are truthful and adequately responsive” further clarifies that neither the statute nor the supporting case law requires multiple misleading or false representations. If these false statements are made under oath, they should be found to be for the purpose of obtaining benefits. Additionally, if they are not under oath, but are made to a doctor, clinic, or hospital where the claimant is obtaining treatment specifically for their workers’ compensation injuries, these should also meet the second prong pursuant to the clear language of the statute.