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  • Worker's Comp Fraud North Carolina

    Doesn't apply to me, but curious. Friend of mine told me this story. An employee from N.C. was injured on the job, he is a Naval veteran, a founding member of the company, instead of reporting the injury to the company's Ins. provider he received surgery from either the State of Virginia or the VA hospital in Virginia (not sure wiche one). I'm not sure of the state or location that the injury occured. But, I do know that N.C. considers the worker's comp policy as being the exclusive remedy for workplace injuries. Also note that his brother and company CEO is a former Ins. adjuster. My thoughts are that they may have commited fraud against a government healthcare provider in an effort to maintain a no injury status w/ thier Ins. provider, and to this day have had a stance of denial to any other workplace injuries. (other claims have been made) Any thoughts?

  • #2
    he is a Naval veteran, a founding member of the company, instead of reporting the injury to the company's Ins. provider
    May be someone overacting here... this would depend on the status..."employee" or "employer", and how the coverage is required by NC WC Act.

    WC insurance is a policy of liability for the employer, the employer is the insured party, not the employee.

    The Act is here http://www.ic.nc.gov/ncic/pages/statute.htm if you'd like to do some research on your question.
    My thoughts are that they may have commited fraud against a government healthcare provider in an effort to maintain a no injury status w/ thier Ins. provider, and to this day have had a stance of denial to any other workplace injuries. (other claims have been made)
    The VA doesn't care about the causation of injury/illness... the vetran is eligible and entitled to treatment.
    Don't know how the State of Virginia would be paying for treatment to this person.

    As to denying claims... it is not the employER option in accepting/denying a claim. An employEE upon injury in the workplace files a injury report, the ER is required to file a claim with their WC carrier. The carrier investigates and determines compensability. It's the IC's job to mitigate the financial exposure to the IC and ER. Nothing out of the ordinary here. Same as would be the case in your own homeowners, auto or any liability coverage you may carry.

    Comment


    • #3
      I know this is old, anyway found out some info to the thread.

      As the situation I described it is in fact a fraud commited against the Federal Government as Worker's Comp is the 'exclusive remedy' of on the job accidents and the VA is entitled to re-imbursement by the companies carrier, as explained to me by a Fed. Law investigative attorney.

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      • #4
        Do you have a cite for that? And what's your stake in this? And are you SURE that this person was an EMPLOYEE, not an owner?
        I am not an attorney, and don't play one on TV. Any information given is a description only and should be verified by your attorney.

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        • #5
          No stake for me. It's bassically the same as using a PHP or dissability sources for work related injuries. The carrier when found to be untimately responsible must pay back for services rendered according to the W's comp laws and/or a judges findings.

          This case is unique in that the work related injuries were in fact never reported to the carrier as well as the state W's comp board, but had been recorded in a court of law to be a work related injury. And this is considered a felony in most states.

          Having instead the VA/taxpayer cover the injuries is in effect passing the buck in the wrong way, by law.

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          • #6
            So, you didn't answer any of my questions.

            1. Do you know, for sure, that this person was an employee?
            2. What is your cite for the law you claim prohibits this person from using the V.A. hospital?
            3. What does this have to do with you? Why do you think this is your business? And please don't answer that as a citizen, everything is your business.

            Unless you are legally trained, chances are you are misinterpreting the law, if you've actually even looked at the statutes.
            I am not an attorney, and don't play one on TV. Any information given is a description only and should be verified by your attorney.

            Comment


            • #7
              1. employee, yes
              nothing more

              2. I never claimed there is a law 'prohibiting' care from anyone.

              3. As a taxpayer, **** right it's my buisiness, your buisiness, everyone's buisiness.

              WC goes to the liability of the ER, your serviceman has shifted the liability to the VA/taxpayer... knowlingly doing so, where there is reasonable expectation of another party holding liability could be fraud against the federal gov't.

              Also there is what's called the 'exclusive remedy doctrine'. It exists in all states, It is the backbone of the W'c comp system.

              Also, failing to report to the state W's comp board if done en-mass can skew the system alltogether changing rates, changing coverage statutes, etc...
              Last edited by Tower Pro; 07-07-2011, 07:56 PM.

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              • #8
                Also, the VA has the right/ability to place a lein on the carrier in the event they are in fact found liable.

                But, the Fed never goes after 'fraud' cases unless they are in excess of millions of dollars. So, no real danger of any litigation taking place.

                And, most states have agreed to the Fed to comply with the sharing of information regarding these situations.

                If it became say 'epidemic' then no doubt legislation would most likely follow.

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                • #9
                  Again, you have provided no citations to support your claims. Sorry, but being a taxpayer doesn't give you the right to be in everyone's business. And if it did, you'd be pretty busy distracting yourself with what you think everyone is doing wrong. And you stated you're hearing about this secondhand anyway. Sounds to me like you need to get a life.
                  I am not an attorney, and don't play one on TV. Any information given is a description only and should be verified by your attorney.

                  Comment


                  • #10
                    I love you guys that need someone to hold your hand to do the discovery for you.

                    Why are you moderating/commenting in the worker's comp section being that you apparently have no clue as to what it is and how it works.

                    Anyone who knows even elementary W's comp knows these things to be true.

                    Another fact is that is is illegal to lie to a healthcare provider/doctor in the state of Virginia as to what caused your injuries. Google THAT.

                    And all providers/doctors ask you as to causation for thier reports.

                    I think you take some kind of offense in regards to the military issue, and I don't care.

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                    • #11
                      BTW, yes taxpayers have a clear stake in such matters.

                      Have you forgotten the AIG bailout so quickly. Another case of the Ins. companies passing the buck to the American people.

                      So any relief given to the Ins. companies when liability is clearly thier's is a mistake and unjust.

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                      • #12
                        And I think you need to realize that you do not necessarily know all the facts. Which is why we kept asking who you are in this scenario.

                        Real life example: Some years ago my then-employer received an internal complaint of age/race discrimination on behalf of a third party. "Liz" complained that "Betty", who was the oldest woman in the all-female department and the only minority, should have been promoted into a supervisory position instead of "Cindy" who was younger (though still over 40) and Caucasian. Betty had been there longer than anyone else and was clearly qualified. From Liz's point of view it was a no-brainer. What Liz didn't know was that the position had been offered to Betty, who turned it down saying she didn't want the extra responsibility, and recommended Cindy as having better qualifications (which, in truth, she did).

                        So perhaps you should consider that maybe there are facts that you don't know about the situation. Since you are not a participant it's not a guarantee that you know all there is to know about it.
                        The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

                        Comment


                        • #13
                          Do you know that a claim can be denied by w.c. so then the employee's own insurance covers the injury? Not all claims are cut and dried and sometimes an injury may happen on property but not be covered (which happened at my company recently)

                          How do you know that the Hospital isn't billing under wc? My employees go to their own doctors if they prefer but bill to wc not their insurance.

                          Worker's comp also varies by state. So you can't use a blanket statement about wc and have it cover every state. Some states don't even require a business to carry it.

                          You have been insulting posters who have taken their own time to answer you. You have insulted our resident wc expert who knows far more than you ever will and a poster who attended law school.

                          If government policies alarm you so much (as with the bailout) then you should be writing your congresspeople, state reps, sentators and president. Being worried about third hand knowledge of a situation does not help it at all.

                          Also when you are up in arms about misuse of the Vet hospital, keep in mind that the man you are talking about served your country! In my opinion that gives him the right to use the Vet Hospital whenever he needs.

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                          • #14
                            Well, since you have all the answers, and we apparently don't know anything, I'm not sure why you're posting here. Do you have a legal question or are you here to inform us of the law that you can't cite? This is a volunteer board, and so far you're just wasting our time.
                            I am not an attorney, and don't play one on TV. Any information given is a description only and should be verified by your attorney.

                            Comment


                            • #15
                              Originally posted by Tower Pro View Post
                              I love you guys that need someone to hold your hand to do the discovery for you.

                              Why are you moderating/commenting in the worker's comp section being that you apparently have no clue as to what it is and how it works.

                              Anyone who knows even elementary W's comp knows these things to be true.

                              Another fact is that is is illegal to lie to a healthcare provider/doctor in the state of Virginia as to what caused your injuries. Google THAT.

                              And all providers/doctors ask you as to causation for thier reports.

                              I think you take some kind of offense in regards to the military issue, and I don't care.
                              How do you know that the entity that provided the medical care didn't bill the employer's worker's compensation insurance carrier??? You're throwing around a lot of definite opinions about fraud against U.S. taxpayers when you clearly don't know all the facts of the situation.

                              Comment

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