South Florida Hospital News
Wednesday May 22, 2019
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July 2010 - Volume 7 - Issue 1

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As Healthcare Insurance Costs Rise, More Fraud Found in Workers' Comp System

According to Kaiser Family Foundation Health Research & Educational Trust, the average cost of health insurance to cover a family in 2009 was $13,375, a 5% increase from the year prior. More startling, however, is that in just nine years, the average family policy more than doubled, from $6,438 to $13,375. Couple these statistics with the current unemployment figures and the reality that companies continue to pass more of the health insurance expense along to their workers, and it becomes crystal clear that affordable insurance seems more like the holy grail than a reasonable expectation.

Whether we read newspapers, surf the Internet, or simply listen to the conversations around us at the local Starbucks, we are inundated with stories about how family and friends cannot afford health insurance. Many of us know of employed family members or friends who are seeing more and more of their wages deducted from their paychecks to pay for health insurance “provided by” the employer. The health insurance crisis has become such an epidemic that even those of us with health insurance cannot afford medical care due to rising deductibles and co-pays. While insurance costs rise and the ability to afford insurance declines, employees and their families continue to suffer health problems that require medical care.
 
Some employees have reacted to this crisis by resorting to unethical, if not illegal means. As a workers’ compensation attorney, I have noticed an increase in the filing of questionable, if not outright fraudulent workers’ compensation claims. Employees now claim that medical conditions, which are personal in nature, were caused through their employment, either through a specific incident or through repetitive trauma/exposure. The employees seek to have these personal conditions paid for by the employer’s workers’ compensation insurance. In some cases, the employees cannot even identify a specific date of accident, and will argue that the condition occurred over time. In other cases, the employees will identify a date of accident and simply have no witnesses to corroborate that the incident occurred. Regardless, if the employee has a personal medical condition, but is unable to afford medical care, that employee now seems more likely to convince himself and others that the condition is employment related.
 
Desperate employees who cannot afford health insurance, even when an employer provides insurance, are attempting to have personal medical conditions covered through the employer’s workers’ compensation policies. Employees will exaggerate, manipulate and at times blatantly misrepresent the medical history of their condition to secure medical care that cannot otherwise be afforded. Due to pressing medical needs and limited financial ability, these employees are less concerned about the ethical/legal implications of their misrepresentations and more concerned about addressing a medical issue that, in many cases, has been ignored for years. While it behooves a carrier, from a cost standpoint, to investigate these claims internally, the reality is that attorneys, like myself, often need to be retained. While the Carrier may never spend a dime on medical care for that employee, the carrier is often spending thousands of dollars to merely investigate a claim with no merit.
 
Healthcare reform will invariably impact the workers’ compensation system in Florida. More affordable health insurance should result in coverage for more employees. More coverage will arguably make employees less likely to resort to unethical/illegal means to secure medical care through the workers’ compensation system and more likely to use their personal insurance to address personal medical conditions. The goal is for employees to view their employer as a road to financial success and not as a backdoor way to secure medical care.
Robert Friedman, attorney for the law firm of Kelley, Kronenberg, Gilmartin, Fichtel, Wander, Bamdas, Eskalyo & Dunbrack, P.A. in Plantation, can be reached at (954) 370-9970.
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