In 2007 State Fund discovered Safehome Inc. was under reporting their employee payroll to avoid paying the proper premium. An audit was completed and indicated that Safehome Inc. had failed to pay the proper premiums for their workers’ compensation policy in the amount of $477,285. Additionally, State Fund determined the business was operating out of its classification, and related payroll was never reported to either State Fund or EDD, according to investigators.
“…the three types of most common workers’ comp fraud – injured worker fraud, provider fraud and premium fraud – haven’t changed much…”
Workers’ compensation fraud costs businesses $7.2 billion annually, roughly a fifth of all workers’ compensation payments, according to the National Insurance Crime Bureau.
In the past, it’s been challenging to prosecute workers’ compensation fraud, but recently passed legislation is making it easier for agencies like State Fund to work together to fight fraud. In June, as a result of a joint task force that included State Fund, more than 100 enforcement actions were taken against companies for failure to comply with state contracting, insurance and payroll requirements.
And earlier this year, State Fund partnered with other agencies on a fraud case that resulted in a conviction with restitution orders to both State Fund and the Employment Development Department.
For more: http://www.insurancejournal.com/news/west/2012/12/12/273777.htm
“…the Medicare Secondary Payer and Workers’ Compensation Settlement Agreements Act of 2012…deals only with workers’ compensation claims, and seeks to establish clear and consistent rules for workers’ compensation set-asides for claimants covered by Medicare…”
“…The Strengthening Medicare and Repaying Taxpayers Act…deals with issues related to the Medicare Secondary Payment Act. Specifically, it deals with mandates for providing timely information on conditional payments, penalties and statutes of limitations when claims are reported to the Centers for Medicare and Medicaid Services by insurers and self-insured and third-party payers on no-fault auto-insurance claims, workers’ compensation claims, and claims under liability insurance…”
Insurance and related industries are seeking to win support in the waning days of the current Congress for two pieces of legislation dealing with payment of injured worker claims to people whose primary insurance is Medicare. Officials of both the American Insurance Association and the Property Casualty Insurers Association of America are urging action on the bills this year.
Nathaniel Wienecke, PCI senior vice president, Wednesday asked officials of the Senate Finance Committee and the House Ways and Means Committee if it could act on the bill this year.
Currently, workers’ compensation claims that overlap with Medicare coverage are subject to lengthy, cumbersome review by the Centers for Medicare and Medicaid Services to establish the proper “set-side” coverage amounts for future medical expenses, according to PCI officials.
For more: http://www.propertycasualty360.com/2012/12/14/insurance-reps-push-for-action-on-medicare-seconda?t=commercial
“…The Tennessee Supreme Court held that a manager was entitled to benefits at the statutory maximum of six times his medical impairment…the manager was denied a meaningful return to work when he was terminated in retaliation for filing his claim. The manager’s age, education, training, work experience, and limitations warranted the six-times multiplier…”
A co-manager for a fast food restaurant was repairing a heating element used to keep food warm. Someone plugged the heating element into an electrical outlet. An electrical shock caused the manager to lose consciousness. He suffered from burns on his hands, chest pains, headaches, and memory loss. He repeatedly asked his supervisor to pay his medical expenses and authorize medical care for his symptoms. The district manager said he would “take care of it,” but the bills remained unpaid. The manager filed a workers’ compensation claim, and the restaurant was fined for failing to timely report the incident. Days after the claim was filed, his supervisor “vulgarly expressed his anger” about the claim. Within weeks, the manager, who had never received a reprimand, received two reprimands and was later terminated.
A neurologist diagnosed the manager with a migraine condition and epilepsy and opined that the conditions were caused by the electrical shock. The neurologist found that he reached maximum medical improvement with a 10 percent impairment to the body as a whole. A vocational expert opined that the manager suffered a 65 percent vocational disability based on his age, limitations, work history, and the local labor market. The manager was unable to find gainful employment other than occasional “odd jobs.” The Tennessee Supreme Court held that he was entitled to benefits at the statutory maximum of six times his medical impairment.
The court rejected the restaurant’s argument that the maximum multiplier possible was meant to punish it for mishandling the claim rather than an assessment of disability.
For more: http://www.riskandinsurance.com/story.jsp?storyId=533352818
The North Carolina Retaliatory Employment Discrimination Act (REDA) outlaws discharging employees for filing workers’ compensation claims. It’s a protected activity.
Equally illegal: Jumping the gun by firing employees before they actually fill out the workers’ compensation paperwork. Employees are also protected when they inform a supervisor that they may be filing a claim soon.
Recent case: Shannon worked as a property manager for M&M Properties for just three weeks. While cleaning a hotel room as part of his training, Shannon said he injured himself. He reported the incident to his supervisor and said he wanted to check with his doctor before filing a workers’ compensation claim in case he had merely pulled a muscle.
Meanwhile, the company issued a disciplinary warning, outlining problems encountered during Shannon’s training, such as tardiness and lack of communication. He was fired a few days later.
He went ahead with filing the workers’ comp claim—and then followed up with a REDA lawsuit. The company argued that because Shannon hadn’t filed a claim before he was terminated, he couldn’t argue retaliation.
The court disagreed. Otherwise, employers would be able to fire employees—and dodge liability—as soon as they got hurt. (Fatta v. M&M Properties Management, No. COA11-1397, Court of Appeals of North Carolina, 2012)
For more: http://www.businessmanagementdaily.com/31679/workers-comp-claim-resist-urge-to-retaliate
“…accusations that he dissuaded an employee from seeking workers’ compensation after a work injury and making false claims. The charges against him include two counts of insurance fraud, failure to maintain workers’ compensation insurance and passing bad checks…”
“…accused of paying approximately $890,000 less than he should have over a four-year period,,,”
The trial date for the owner of the troubled Brookdale Inn & Spa has been postponed because the District Attorney’s Office has filed more charges. Sanjiv Kakkar originally was scheduled to begin trial March 12 on accusations that he dissuaded an employee from seeking workers’ compensation after a work injury and making false claims. The charges against him include two counts of insurance fraud, failure to maintain workers’ compensation insurance and passing bad checks, according to Kelly Walker, a prosecutor with the Santa Cruz County District Attorney’s Office.
Walker has just filed new insurance fraud charges against Kakkar and his wife, Neelam Kakkar, pertaining to insurance premiums. Kakkar is accused of providing false wage information to insurance companies to obtain lower premiums. In other words, he “grossly understated” the amount of payroll he was paying to his employees. He stands accused of paying approximately $890,000 less than he should have over a four-year period, according to Walker.
For more: http://www.mercurynews.com/breaking-news/ci_20133381/das-office-files-more-insurance-fraud-charges-against
“…the appeals court agreed with previous rulings, which denied a request for additional treatment after diagnostic tests showed “no recurrent hernia and surgery to explore the scrotum” and saw no abuse by the courts in allowing the photos…In denying Clement’s request for additional compensation and treatment, the court ruled in favor of the use of Facebook photos as a evidence…”
An appeals court has ruled that photos on Facebook and Myspace of a man “drinking and partying” can be used as evidence to deny him further workers compensation claims.
At the center of the suit is Zackery Clement, who suffered a hernia March 12, 2009 after a refrigerator fell on him while on the job at Johnson’s Warehouse Showroom in Pine Bluff, Ark. Clement, who was compensated for medical expenses and received temporary total-disability benefits for more than a year, was seeking an extension of benefits following three surgeries as a result of the injury.
An administrative law judge and the Arkansas Compensation Commission denied Clement’s application for additional benefits, and Clement, 27, was hoping the Arkansas Court of Appeals would reverse the ruling. He argued that he needed further medical treatment and disability payments because of “excruciating pain.”
For more: http://abcnews.go.com/blogs/business/2012/02/court-okays-facebook-party-photos-in-workers-comp-claim/
“…dividends come back to restaurants participating in the TRA’s workers comp insurance program… creates incentives for the restaurants to have a safety program and to work with the insurance company and the employees to maintain a safer workplace….”
“Every year we get back … a little over half of our premium that we paid. So, it’s a big return of an expense,” says Lindskog whose company has been in the program since 2004. “A lot of people don’t want workers comp insurance because it’s expensive. But if you get half of it back, it makes it much more cost effective for your restaurant.”
Texas Mutual is the leading provider of workers comp insurance in the state. It was created by the Texas Legislature in 1991 when major reforms on workers comp became effective. Its board of directors is composed of individuals from companies it insures as well as those appointed by the governor of Texas.
For more: http://www.bizjournals.com/sanantonio/news/2012/01/25/san-antonio-restaurants-score-rebate.html?page=2
“…Many (restaurants) are turning to innovations to grow their business. While that can be a plus for their balance sheets, it can also open the door to unexpected liabilities that their insurance policies were not designed to cover…”
Agents can head off this scenario and build a strong consultative relationship with their restaurant customers by asking key questions at renewal time. Here are some of the trends that could put restaurants at risk and the questions agents should ask their restaurant customers :
- Mobility. Has the restaurant added new services, such as delivery of meals using hired drivers with their own cars?
- Branch out businesses. Has the restaurant started a new line of business, such as catering?
- Trendy foods. Has the restaurant introduced new menu offerings as part of the strategy for attracting more customers, such as locally sourced foods, an emphasis on organic ingredients or assurances about non-allergenic ingredients?
- Additional payment methods. Is the restaurant accepting new methods of payment, such as online credit charges or smartphone purchasing?
All too often, the lack of appropriate coverage only becomes evident when a mishap occurs and a claim is filed. After someone has already threatened to sue for damages is usually a bad time for restaurant owners to discover they should have consulted with their insurance agent about their insurance needs before changing their business model.
For more: http://www.propertycasualty360.com/2012/01/12/4-trends-that-can-put-restaurants-at-risk
Learning the rights of an injured worker under California’s workers’ compensation system. This video follows several workers’ compensation case scenarios and provides basic information and resources for obtaining further assistance and/or information.
“…accused of dissuading an employee from seeking workers’ compensation after a work injury, fraud and making false claims. He is charged with two counts of insurance fraud, failure to maintain workers’ compensation insurance …”
The owner of a long-troubled Santa Cruz area inn is headed to trial on charges that he mishandled workers’ compensation and committed insurance fraud.
Sanjiv Kakkar, owner of Brookdale Inn and Spa, is accused of dissuading an employee from seeking workers’ compensation after a work injury, fraud and making false claims. He is charged with two counts of insurance fraud, failure to maintain workers’ compensation insurance and passing off bad checks, according to Kelly Walker, a prosecutor with the Santa Cruz District Attorney’s Office.
Kakkar appeared in court Friday with his attorney, Peter Leeming, to set a date of March 12 for a jury trial. A court date was also scheduled for December for a motion to consolidate the case with a second criminal case involving Kakkar. The latter case involves misdemeanor violations of health and safety codes.
Leeming said he is looking forward to finally taking the case to trial after multiple delays.
For more: http://www.mercurynews.com/central-coast/ci_19167190