Failure to disclose prior relevant medical history results in a dismissal with prejudice of petitioner's claim and carrier is reimbursed for previously paid temporary benefits.
On August 4, 2008, the petitioner sustained injury to his right knee while in the course of his employment with the respondent. The petitioner was authorized for treatment with an orthopedist. An August 28, 2008, MRI of the petitioner's right knee showed a tear involving the posterior horn of the medial meniscus, a "sprain" of both the anterior cruciate ligament and the medial collateral ligament, and a "trace" Baker's cyst. The orthopedist's treatment notes indicated that the petitioner denied any prior history of right knee injury. On September 18, 2008, the petitioner underwent an arthroscopic partial medial meniscectomy of the right knee, requiring time out of work. The respondent paid temporary benefits during this period of time. On March 5, 2009, the petitioner was assessed at maximum medical improvement by another doctor, whose report indicated that the petitioner denied any problems with respect to his right knee prior to his August 4, 2008, work-related accident.
On November 5, 2008, the petitioner filed a claim with the Division of Workers' Compensation alleging injury to his right knee as a result of an accident arising out of and in the course of his employment. While conducting its investigation, the respondent determined that the petitioner had been involved in an April 13, 2007, motor vehicle accident in which he sustained injury to his right knee and for which he sought treatment with an orthopedic surgeon. An August 25, 2007, an MRI of the petitioner's right knee revealed a tear of the posterior horn of the medial meniscus, a partial tear of the anterior cruciate ligament and a small Baker's cyst. The orthopedic surgeon's October 10, 2007, treatment notes indicated that the petitioner was subsequently recommended for a surgical arthroscopy of the right knee. That notwithstanding, the petitioner never underwent the recommended procedure for reasons unspecified. However, the petitioner did bring a civil action in connection with his motor vehicle accident and indicated in answers to interrogatories prepared on December 15, 2008, that as a result of this accident he suffered permanent injury to his right knee, which continued "to limit his activities.”
At trial, the petitioner testified that he had no problems with his right knee until after his August 4, 2008, work-related accident. When asked to explain the apparent contradiction between his testimony and interrogatory answers, the petitioner simply indicated that his answers to interrogatories were incorrect. As to his prior motor vehicle accident, the petitioner testified that he had no recollection of having been told by the orthopedic surgeon that he had sustained a tear of the medial meniscus. However, later in his testimony, the petitioner contradicted himself when he stated that the orthopedic surgeon had advised him that he would require surgery of the right knee because of a "partial tear of the ACL."
At the conclusion of the trial, the respondent moved for dismissal of the petitioner's claim as well as reimbursement of temporary benefits that had been paid to the petitioner. In support of its motion, the respondent invoked the New Jersey Workers' Compensation Fraud Act, N.J.S.A. 34:15-57.4(c), which provides that a person who:
Purposefully or knowingly makes, when making a claim for benefits pursuant to N.J.S.A 34:15-1 et seq., a false or misleading statement, representation or submission concerning any fact which is material to that claim for the purpose of obtaining benefits, the Division may order the immediate termination or denial of benefits with respect to that claim and a forfeiture of all rights of compensation or payments sought with respect to the claim. N.J.S.A. 34:15-57.4(c)(1).
Further, N.J.S.A. 34:15-57.4(c)(2) provides, "[i]f that person has received benefits pursuant to [the Act], to which the person is not entitled, he is liable to repay that sum . . . to the employer or the carrier."
The Judge of Compensation found that the petitioner's failure to disclose his prior right knee injury was a deliberate and material omission designed to enhance his prospective award of benefits. Accordingly, the Judge dismissed the petitioner's claim with prejudice, ordered the forfeiture of rights to future compensation with respect to the claim and granted the respondent's request for reimbursement of previously issued temporary benefits. The petitioner appealed.
In affirming, the Appellate Division concluded that there was competent credible evidence to support the Judge of Compensation's determination that the petitioner's conduct violated N.J.S.A. 34:15-57.4(c). That evidence included: (1) the similar MRIs, which were performed before and after the work-related accident; (2) the petitioner's interrogatory answers describing as permanent and limiting the injuries he sustained as a result of his April 13, 2007, motor vehicle accident; and (3) the reports of the orthopedist and the orthopedic surgeon, both of which explicitly stated that the petitioner denied suffering any injury to his right knee prior to his August 4, 2008, workplace accident.
Case Law Alert - 4th Qtr 2012