Fraud

MONTANA SUPREME COURT DECISIONS

Taylor v. State Compensation Insurance Fund, 175 Mont. 432, 913 P.2d 1242 (1996) Supreme Court affirmed determination of Workers’ Compensation Court that two of truck driver’s three claims were fraudulent. Contrary to claimant’s argument on appeal, the lower Court’s determination of fraud did not rest entirely on testimony of individuals who said claimant told him he was “scamming the system.” Rather, the lower Court based its determination on extensive review of the entire record, including medical evidence, the testimony of all the witnesses, and the credibility of the witnesses. This evidence included indication that several physicians could not find an objective basis for claimant’s pain complaints and that his pain complaints were out of line with the objective medical findings.

MONTANA WORKERS' COMPENSATION COURT DECISIONS

Montana State Fund v. Simms [01/09/08] 2008 MTWCC 3 In situations alleging fraud or deception, this Court need no longer look to Mont. R. Civ. P. 60(b) because § 39-71-2909, MCA, as amended in 1995, now covers situations in which fraud or deception is alleged. Therefore under § 39-71-2909, MCA, this Court has the jurisdiction to consider a petition for declaratory ruling which alleges a claimant fraudulently obtained benefits.

UEF v. Big Sky Petroleum, Montana State Fund, and Melvin J. Strong [4/29/04] 2004 MTWCC 39 Insurer may rescind acceptance of claim and deny further benefits for fraud or misrepresentation which vitiates the acceptance. Where insurer accepted claim based on an incorrect date of injury which was supplied by employer and did not insure the employer on the date when the injury in fact occurred, the insurer properly rescinded its acceptance and denied further benefits.

Higgins v. Liberty NW [3/23/04] 2004 MTWCC 31  Fraud must be affirmatively pled. However, where the facts constituting the alleged fraud are discovered during discovery following the filing of the petition, leave to file an amended petition will be granted even though the constructive fraud theory was identified and proffered shortly before the pretrial conference.

Schneider v. Liberty Mutual Ins. [4/20/01] 2001 MTWCC 14 Claimant's lack of credibility, his drug-seeking behavior, his attempts to obtain narcotics from a physician two days prior to his alleged industrial accident, his knowledge that he was unlikely to keep his current job, his recent history of allegedly debilitating headaches which he claimed got him fired a month and a half previously from a previous job and in connection with which he was seeking narcotics, his odd statements to his coworkers, the incongruity between the manner in which he claimed the accident occurred and the physical layout of the place of the accident, his subsequent drug seeking behavior, and his documented lies persuade the Court that the claimed industrial accident was staged and was fraudulent.

Hodge v. State Fund [1/17/01] 2001 MTWCC 1Res judicata, collateral estoppel and double jeopardy doctrines do not preclude an insurer, even a governmentally state sponsored insurer such as the State Fund, from raising an affirmative defense of fraud with respect to benefits due a claimant despite claimant's acquittal of fraud charges in a criminal action.

Miller v. State Fund [9/20/00] 2000 MTWCC 63 Claimant's motion in limine to exclude evidence of fraud at trial was not proper where claimant, in essence, sought to strike an affirmative defense but had not moved for partial summary judgment or to strike. The motion to exclude was also denied because no agreement to drop fraud defense arose from communications to Clerk of Court by counsel.

Jensen v. State Fund [4/2/99] 1999 MTWCC 25 Carpet installer claimed he fell down stairs at work, having grabbed a broken handrail, and was injured. After hearing testimony from several witnesses, including that of claimant's brother and sister-in-law that claimant spoke about staging a fall at work "for his retirement," WCC concluded claim was fraudulent.

Taylor v. State Fund [8/21/95] 1995 MTWCC 61 and Taylor v. State Fund [10/6/95] 1995 MTWCC 77 With regard to two of three claims filed by truck driver, insurer sustained its burden of proving fraud, entitling the insurer to an order of reimbursement from claimant for medical and compensation benefits paid on the two claims. In finding the insurer proved the nine required elements of fraud, the Court relied on credible testimony of witnesses who said claimant told them he was “scamming the system,” but also on evidence that claimant had a financial motive, was unhappy with his job and angry at his supervisors, inconsistencies in claimant’s statements to medical providers and others, lack of objective medical evidence of some injuries, and evidence that claimant exaggerated and fabricated injuries and symptoms, some of which were anatomically inappropriate.