A PUBLICATION BY THE LAW FIRM OF

Clifton, Mueller & Bovarnick, P.C.

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ATTORNEYS AT LAW

2006

AUGUST

CMB Welcomes Kimberly Quinn as

Our Newest Associate

Kimberley A. Quinn was admitted to the Colorado Bar Association in 1997 after graduating from the University of Colorado School of Law. After completing a one-year judicial clerkship with District Court Judge Morris W. Sandstead, Ms. Quinn joined the Denver District Attorney’s office as a criminal prosecutor. Ms. Quinn has extensive litigation experience, including more than 40 jury trials. Her current practice focuses on defense of employers in employment cases, defense of employers and insurance carriers in workers’ compensation cases and general civil litigation. Ms. Quinn is a member of the Colorado and Denver Bar Associations.

Penalty (pen’əl tē) n., pl. - ties 1. Improper Termination of TTD

By Michael Curry

It just cannot be emphasized enough.  The quickest way to find yourself (and your carrier) on the losing end of a claim for penalties is to improperly terminate TTD.

The Industrial Claim Appeals Office issued yet another decision reinforcing this theory.  The claimant in Maria Adakai v. St. Mary Corwin Hospital, W.C. Number: 4-619-954 (May 5, 2006), sustained an injury in a compensable motor vehicle

It is axiomatic that fraud in workers’ compensation cases is easy to allege, but difficult to prove.  C.R.S. § 8-43-402 provides that, “If, for the purpose of obtaining any order, benefit, award, compensation, or payment under the provisions of [The Workers’ Compensation Act], either for self-gain or for the benefit of any other person, anyone willingly makes a false statement or representation material to the claim, such person commits a class 5 felony and shall be punished as provided in C.R.S. § 18-1-105, and shall forfeit all right to compensation under [The Workers’ Compensation Act] upon conviction of such offense.” 

The DWC’s Investigations & Criminal Enforcement Unit has indicated it must be able to prove the following in order to build a “prosecutable case”:

1) The statements or representations made were false;

accident. Respondents admitted liability for TTD benefits. 

Claimant’s treating physician placed her at MMI on February 11, 2005, without permanent impairment.  Three days later, the treating physician’s office telephoned the insurance claims adjustor and notified her that the claimant reached MMI on February 11.  The adjustor immediately terminated temporary disability benefits,

believing that she would be overpaying claimant if she waited for the written MMI report.  The adjustor received the report on February 22 and filed the FAL March 21 admitting for TTD through February 11.

At hearing, ALJ Mattoon imposed a penalty of $200 per day for improper termination of TTD. The total penalty levied against respondents amounted to

2) The claim decisions were made based on false statements or representations material to the claim; and

3) The statements or representations were made with intent to defraud.

A fairly common scenario arises when a claims professional learns that a claimant is working while receiving TTD benefits.  Is this fraud?  Only if the person made a material false statement or representation.

These types of cases are very fact-specific.  If you suspect fraud in one of your cases, begin your analysis by determining whether you have evidence that a person willingly made a false statement or representation about something “material to the claim,” for the purpose of getting benefits.  If you do, contact the DWC’s Investigations & Criminal Enforcement Unit at 303-318-8227 to discuss the case further, and don’t hesitate to contact any of the Clifton, Mueller & Bovarnick attorneys for assistance.

Fraud and Workers’ Compensation

By Royce Mueller