This article was written with the assistance of AI and edited by Angela Sabarese.
In a recent CLM webinar, experts Barbara Glas and Paulette Brown, both shareholders with Kubicki Draper; and Scottie Benton, vice president of workers' compensation practice with Sedgwick Claims Management Services, talked about how to best support misrepresentation defense in workers’ compensation cases.
The panelists discussed Florida statutes 440.09 and 440.105, which govern misrepresentation in workers' compensation claims. Glas outlined the legal framework of the statutes, explaining how they work together to address fraudulent claims, while emphasizing the critical distinction between misrepresentation and outright fraud based on intent and deliberate deception.
Red Flag Fraud Indicators
Benton provided insights from the claims handling perspective, detailing red flag indicators that suggest potential fraud. These include behavioral indicators like poor attendance records; situational factors such as weekend injuries reported on Monday morning; and claim-related anomalies like frequent prior claims or reluctant witnesses. "Remember, the presence of one or even several red flags [do] not confirm fraud," Benton cautioned. "These indicators are meant to trigger a deeper review by the claims adjuster, by the employer, and/or investigators. None of these prove fraud on their own."
Building a Misrepresentation Case
Brown presented the attorney's approach to building misrepresentation cases, emphasizing thorough fact-gathering including witness interviews, medical record reviews, surveillance, and claimant depositions. She shared a compelling case example where surveillance contradicted a claimant's testimony about his physical limitations, resulting in a settlement for less than $5,000 instead of the six-figure permanent total disability claim initially sought.
Glas stressed the fundamental legal requirement: "Misrepresentation defense requires a showing of knowingly or intentionally made a fraudulent or misleading statement. Those are the keywords: knowingly [and] intentionally. [E]verything has to have an intent."
The presentation highlighted that successful misrepresentation defense requires coordinated efforts between claims handlers, special investigative units, and attorneys, with comprehensive documentation and evidence-gathering being essential for effective case resolution.