Workers Compensation Fraud Case

Workers' compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence. The tradeoff between assured, limited coverage and lack of recourse outside the worker compensation system is known as "the compensation bargain".
While plans differ among jurisdictions, provision can be made for weekly payments in place of wages (functioning in this case as a form ofdisability insurance), compensation for economic loss (past and future), reimbursement or payment of medical and like expenses (functioning in this case as a form of health insurance), and benefits payable
to the dependents of workers killed during employment (functioning in this case as a form of life insurance).
General damage for pain and suffering, and punitive damages for employer negligence, are generally not available in workers' compensation plans, and negligence is generally not an issue in the case. These laws were first enacted in Europe and Oceania, with the United States following shortly thereafter.

Statutory compensation law[edit]
Workers' compensation statutes are designed to ensure that employees who are injured or disabled on the job are not required to cover medical bills related to their on-the-job injury, and are provided with monetary awards to cover loss of wages directly related to the accident, as well as to compensate for permanent physical impairments. The intent of these statutes is to eliminate the need for litigation by having employees give up the potential for pain- and suffering-related awards in exchange for not being required to prove tort (legal fault) on the part of their employer.
These laws also provide benefits for dependents of those workers who are killed because of work-related accidents or illnesses. Some laws also protect employers and fellow workers by limiting the amount an injured employee can recover from an employer and by eliminating the liability of co-workers in most accidents. State statutes [in the United States] establish this framework for most employment. Federal statutes [in the United States] are limited to federal employees or those workers employed in some significant aspect of interstate commerce.[1]
The fairness of workers' compensation statutes is highly controversial, with the claimants (injured workers) and claimant attorneys arguing the need for greater benefits, and the employer/insurance carrier side arguing that excessive fraud in the system causes unnecessary and inappropriate costs.
Workers' compensation fraud[edit]
Fraud is a problem which plagues workers' compensation systems in every country, with billions of dollars being spent in unnecessary litigation, surveillance, legal fees, and settlements worldwide.[citation needed] Workers' compensation fraud is committed by doctors, lawyers, employers, insurance company employees and claimants, and occurs in both the private and public sectors.[2]
The topic of workers' compensation fraud is highly controversial, with claimant supporters arguing that fraud by claimants is rare – as low as one-third of one percent,[3] others focusing on the widely reported National Insurance Crime Bureau statistic that workers' compensation fraud accounts for $7.2 billion in unnecessary costs,[4] and government entities acknowledging that "there is no generally accepted method or standard for measuring the extent of workers' compensation fraud ...
as a consequence, there are widely divergent opinions about the size of the problem and the relative importance of the issue."[5]
According to the Coalition Against Insurance Fraud, tens of billions of dollars in false claims and unpaid premiums are stolen in the U.S. alone every year.[6]
The most common forms of workers' compensation fraud by workers
are:
1. Remote injury. Workers get injured away from work, but say they were hurt on the job so that their workers' compensation policy will cover the medical bills.
2. Inflating injuries. A worker has a fairly minor job injury, but lies about the magnitude of the injury in order to collect more workers' compensation money and stay away from work longer.
3. Faking injuries. Workers fabricate an injury that never took place, and claim it for workers' compensation benefits.[7]
4. Old injury. A worker with an old injury that never quite healed claims it as a recent work injury in order to get medical care covered.
5. Malingering. A worker stays home by pretending the disability is ongoing when it is actually healed.
6. Failure to Disclose. A worker knowingly, or unknowingly, makes a false statement or representation about their injury. [8]
It is however, impossible to fake MRI and/or CT scans and notwithstanding this fact, many still claim that workers injuries are not genuine even when the evidence shows otherwise. Insurance campanies routinely employ doctors who are in their pocket. These doctors will write medical reports and make their opinion that in almost all cases they see, that the injured worker is suffering from anything else other than the injury caused to them whilst at work. These doctors are committing a fraud and are in effect ethically compromised and morally corrupt.
The most common forms of workers' compensation fraud by employers are:
1. Underreporting payroll. An employer reports that workers are paid less than they actually are in order to lower their premiums.
2. Inflating experience. An employer claims workers are more experienced than they actually are in order to make them seem less risky and therefore less expensive to cover.
3. Evasion. An employer fails to obtain workers' compensation for their employees when it is required by law. Workers are often deceived into thinking they are covered when they are not.[9]
Workers' compensation by nation[edit]
Australia[edit]
As Australia experienced a relatively influential labour movement in the late 19th and early 20th century, statutory compensation was implemented very early in Australia. Each territory has its own legislation and its own governing body.
A typical example is WorkSafe Victoria, which manages Victoria's workplace safety system. Its responsibilities include helping employees avoid workplace injuries occurring, enforcement of Victoria's occupational and safety laws, provision of reasonably priced workplace injury insurance for employers, assisting injured workers back into the workforce, and managing the workers' compensation scheme by ensuring the prompt delivery of appropriate services and adopting prudent financial practices.[10]
Compensation law in New South Wales has recently (2013) been overhauled by the state government. In a push to speed up the process of claims and to reduce the amount of claims, a threshold of 11% WPI (whole person impairment) was implemented.
Workers' compensation regulators for each of the states and territories are as follows:[11]
Australian Capital Territory – Work Safe Act
New South Wales – Work Cover NSW
Northern Territory – NT Work Safe
Queensland – The Workers' Compensation Regulator (formerly Q-COMP)
South Australia – ReturnToWork SA (from 1st July 2015)
Tasmania – WorkCover Tasmania
Victoria – WorkSafe Victoria
Western Australia – WorkCover WA
Brazil[edit]
The National Social Insurance Institute (in Portuguese, Instituto Nacional do Seguro Social – INSS) provides insurance for those who contribute. It is a public institution that aims to recognize and grant rights to its policyholders. The amount transferred by the INSS is used to replace the income of the worker taxpayer, when he or she loses the ability to work, due to sickness, disability, age, death, involuntary unemployment, or even pregnancy and imprisonment. During the first 15 days the worker's salary is paid by the employer and after that by the INSS, as long as the inability to work lasts. Although the worker's income is guaranteed by the INSS, the employer is still responsible for any loss of working capacity, temporary or permanent, when found negligent or when its economic activity involves risk of accidents or developing labor related diseases.
Canada[edit]
Workers' compensation was Canada's first social program to be introduced as it was favoured by both workers' groups and employers hoping to avoid lawsuits. The system arose after an inquiry by Ontario Chief Justice William Meredith who outlined a system in which workers were to be compensated for workplace injuries, but must give up their right to sue their employers. It was introduced in the various provinces at different dates. Ontario was first in 1915, Manitoba in 1916, and British Columbia in 1917. It remains a provincial responsibility and thus the rules vary from province to province. In some provinces, such as Ontario's Workplace Safety and Insurance Board, the programme also has a preventative role ensuring workplace safety. In British Columbia, the occupational health and safety mandate (including the powers to make regulation, inspect and assess administrative penalties) is legislatively assigned to the Workers' Compensation Board of British Columbia WorkSafeBC. In most provinces the workers' compensation board or commission remains concerned solely with insurance. The workers' compensation insurance system in every province is funded by employers based on their payroll, industry sector and history of injuries (or lack thereof) in their workplace (usually referred to as "experience rating").
Germany[edit]
Main article: Worker's compensation (Germany)
The German worker's compensation law of 6 July 1884,[12] initiated by Chancellor Otto von Bismarck,[13][14] was passed only after three attempts and was the first of its kind in the world.[15] Similar laws passed in Austria in 1887, Norway in 1894, and Finland in 1895.[16]
The law paid indemnity to all private wage earners and apprentices, including those who work in the agricultural and horticultural sectors and marine industries, family helpers and students with work-related injuries, for up to 13 weeks.
Workers who are totally disabled get continued benefits at 67% after 13 weeks, paid by the accident funds, financed entirely by employers.
The German compensation system has been taken as a model for many nations.
Japan[edit]
Main article: Workers' accident compensation insurance
(Japan)
Workers' accident compensation insurance is paired with unemployment insurance and referred to collectively as labor insurance.[17][18] Workers' accident compensation insurance is managed by the Labor Standards Office.[19]
Mexico[edit]
Main article: Worker's compensation (Mexico)
The Mexican Constitution of 1917 defined the obligation of employers to pay for illnesses or accidents related to the workplace. It also defined social security as the institution to administer the right of workers, but only until 1943 was the Mexican Social Security Institute created (IMSS). Since then, IMSS manages the Work Risks Insurance in a vertically integrated fashion: registration of workers and firms, collection, classification of risks and events, and medical and rehabilitation services. A reform in 1997 defined that contributions are related to the experience of each employer. Public sector workers are covered by social security agencies with corporate and operative structures similar to those of IMSS.