Glossary Check
Fraud might feel like of those “I-know-it-when-I-see-it” kinds of things, but determining whether or not certain conduct counts as workers’ compensation “fraud” under legal definitions can prove pivotal to a worker’s future.
Thanks to Simply Research, we cover what “fraud” means under Pennsylvania workers’ comp law.
What is ‘Fraud’?
A person, including, but not limited to, the employer, the employee, the health care provider, the attorney, the insurer, the State Workmen’s Insurance Fund and self-insureds, commits an offense if the person does any of the following:
(1) Knowingly and with the intent to defraud a State or local government agency files, presents or causes to be filed with or presented to the government agency a document that contains false, incomplete or misleading information concerning any fact or thing material to the agency’s determination in approving or disapproving a workers’ compensation insurance rate filing, a workers’ compensation transaction or other workers’ compensation insurance action which is required or filed in response to an agency’s request.
(2) Knowingly and with intent to defraud any insurer presents or causes to be presented to any insurer any statement forming a part of or in support of a workers’ compensation insurance claim that contains any false, incomplete or misleading information concerning any fact or thing material to the workers’ compensation insurance claim.
(3) Knowingly and with the intent to defraud any insurer assists, abets, solicits or conspires with another to prepare or make any statement that is intended to be presented to any insurer in connection with or in support of a workers’ compensation insurance claim that contains any false, incomplete or misleading information concerning any fact or thing material to the workers’ compensation insurance claim.
(4) Engages in unlicensed agent or broker activity as defined by the act of May 17, 1921 (P.L.789, No.285), known as “The Insurance Department Act of 1921,” knowingly and with the intent to defraud an insurer or the public.
(5) Knowingly benefits, directly or indirectly, from the proceeds derived from a violation of this section due to the assistance, conspiracy or urging of any person.
(6) Is the owner, administrator or employee of any health care facility and knowingly allows the use of such facility by any person in furtherance of a scheme or conspiracy to violate any of the provisions of this section.
(7) Knowingly and with the intent to defraud assists, abets, solicits or conspires with any person who engages in an unlawful act under this section.
(8) Makes or causes to be made any knowingly false or fraudulent statement with regard to entitlement to benefits with the intent to discourage an injured worker from claiming benefits or pursuing a claim.
(9) Knowingly and with the intent to defraud makes any false statement for the purpose of avoiding or diminishing the amount of the payment in premiums to an insurer or self-insurance fund.
(10) Knowingly and with intent to defraud, fails to make the report required under section 311.1.
(11) Knowingly and with intent to defraud, receives total disability benefits under this act while employed or receiving wages.
(12) Knowingly and with intent to defraud, receives partial disability benefits in excess of the amount permitted with respect to the wages received.
