Glossary Check
Workers’ compensation fraud might be the kind of thing that you think you know when you see, but state law usually has a definition for it. That’s the case in Hawaii, which, as Simply Research subscribers know, state law defines as follows at HRS § 386-98(a).
A fraudulent insurance act, shall include acts or omissions committed by any person who intentionally or knowingly acts or omits to act so as to obtain benefits, deny benefits, obtain benefits compensation for services provided, or provides legal assistance or counsel to obtain benefits or recovery through fraud or deceit by doing the following:
(1) Presenting, or causing to be presented, any false information on an application.
(2) Presenting, or causing to be presented, any false or fraudulent claim for the payment of a loss.
(3) Presenting multiple claims for the same loss or injury, including presenting multiple claims to more than one insurer except when these multiple claims are appropriate and each insurer is notified immediately in writing of all other claims and insurers.
(4) Making, or causing to be made, any false or fraudulent claim for payment or denial of a health care benefit.
(5) Submitting a claim for a health care benefit that was not used by, or on behalf of, the claimant.
(6) Presenting multiple claims for payment of the same health care benefit.
(7) Presenting for payment any undercharges for health care benefits on behalf of a specific claimant unless any known overcharges for health care benefits for that claimant are presented for reconciliation at that same time.
(8) Misrepresenting or concealing a material fact.
(9) Fabricating, altering, concealing, making a false entry in, or destroying a document.
(10) Making, or causing to be made, any false or fraudulent statements with regard to entitlements or benefits, with the intent to discourage an injured employee from claiming benefits or pursuing a workers’ compensation claim.
(11) Making, or causing to be made, any false or fraudulent statements or claims by, or on behalf of, a client with regard to obtaining legal recovery or benefits.
Case Example
Tauese v. State of Hawaii, Department of Labor and Industrial Relations, 147 P. 3d 785 (Haw. 2006). In the context of HRS § 386-98(a), for a fraudulent insurance act to occur, the “logical result or purpose” of “acts or omissions” must be “to obtain benefits.” HRS § 386-98(a), then, does not require that a party actually obtain benefits to be subject to a penalty. It only requires that obtaining benefits was the “logical result or purpose,” Webster’s Third New Int’l Dictionary at 2160 (emphasis added), of the party’s “acts or omissions,” HRS § 386-98(a). By its terms, HRS § 386-98(a) would include an attempt to obtain benefits inasmuch as the “outcome” of obtaining benefits was the “purpose” of Appellant’s actions.
