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Hawaii Workers' Compensation Fraud
§386-98 Fraud violations and penalties.
(a) A fraudulent insurance act, under this chapter, 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:
- Presenting, or causing to be presented, any false
information on an application;
- Presenting, or causing to be presented, any false or
fraudulent claim for the payment of a loss;
- 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;
- Making, or causing to be made, any false or
fraudulent claim for payment or denial of a health care benefit;
- Submitting a claim for a health care benefit that was
not used by, or on behalf of, the claimant;
- Presenting multiple claims for payment of the same
health care benefit;
- 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;
- Misrepresenting or concealing a material fact;
- Fabricating, altering, concealing, making a false
entry in, or destroying a document;
- 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; or
- 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.
(b) No employer shall wilfully make a false statement or
representation to avoid the impact of past adverse claims experience
through change of ownership, control, management, or operation to directly
obtain any workers' compensation insurance policy. (c) It shall be
inappropriate for any discussion on benefits, recovery, or settlement to
include the threat or implication of criminal prosecution. Any threat or
implication shall be immediately referred in writing to:
- The state bar if attorneys are in violation;
- The insurance commissioner if insurance company
personnel are in violation; or
- The regulated industries complaints office if health
care providers are in violation, for investigation and, if
appropriate, disciplinary action.
(d) An offense under subsections (a) and (b) shall
constitute a:
- Class C felony if the value of the moneys obtained or
denied is not less than $2,000;
- Misdemeanor if the value of the moneys obtained or
denied is less than $2,000; or
- Petty misdemeanor if the providing of false
information did not cause any monetary loss.
Any person subject to a criminal penalty under this section
shall be ordered by a court to make restitution to an insurer or any other
person for any financial loss sustained by the insurer or other person
caused by the fraudulent act. (e) In lieu of the criminal penalties set
forth in subsection (d), any person who violates subsections (a) and 9b)
may be subject to the administrative penalties of restitution of benefits
or payments fraudulently received under this chapter, whether received
from an employer, insurer, or the special compensation fund, to be made to
the source form which the compensation was received, and one or more of
the following:
- A fine of not more than $10,000 for each violation;
- Suspension or termination of benefits in whole or in
part;
- Suspension or disqualification from providing medical
care or services, vocational rehabilitation services, and all other
services rendered for payment under this chapter;
- Suspension or termination of payments for medical,
vocational rehabilitation and all other services rendered under this
chapter;
- Recoupment by the insurer of all payments made for
medical care, medical services, vocational rehabilitation services,
and all other services rendered for payment under this chapter; or
- Reimbursement of attorney's fees and costs of the
party or parties defrauded.
(f) With respect to the administrative penalties set forth
in subsection (e), no penalty shall be imposed except upon consideration
of a written complaint that specifically alleges a violation of this
section occurring within two years of the date of said complaint. A copy
of the complaint specifying the alleged violation shall be served promptly
upon the person charged. The director or board shall issue, where a
penalty is ordered, a written decision stating all findings following a
hearing held not fewer than twenty days after written notice to the person
charged. Any person aggrieved by the decision may appeal the decision
under sections 386-87
and 386-88.
[L 1963, c 116, pt of §1; Supp, §97-113; HRS §386-98; am L 1982, c 98,
§1; am L 1985, c 296, §7; am L 1995, c 234, §16; am L 1996, c 260, §5]
RED FLAGS
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the injured worker is a new hire; |
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employee refuses treatment; |
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injury occurs immediately before a
possible termination or layoff; |
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suspicious doctors or attorney's; |
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no witnesses of the injury; |
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conflicting descriptions of injury with
first report injury; |
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claimant is hard to reach (no point's
of contact on file); |
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type of injury is unusual for the
applicant's line of work; |
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delays made in reporting the claim; |
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claimant has a history of frequently
changing jobs, phone numbers, or residence; |
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and, employee has a prior history of
claims and/or reporting "subjective" injuries. |
Surveillance video & photography most
effective tool against fraud.
In cases involving fraudulent Workers'
Compensation claims, our investigators and detectives carry out long-term covert
observation of the subject. If the investigator observes the
subject performing an activity that contradicts injuries stated in a
workers' compensation claim, the investigator would take video or still
photographs to document the activity and report it to the client.
AOE/COE (Arising Out of and in the Course of Employment)
Any injury must meet the test of both AOE/COE in order to be eligible for
compensation under the workers' compensation system. The purpose of
an AOE/COE investigation is to establish if the employee's injury was work
related or whether the injury was non-industrial or if there were any
third parties that may have contributed to the injury. A criminal
records search may reveal injuries during an arrest or other altercation.
Interviews may provide leads for further investigations.
The Bureau of Private Investigation's requisite
professional credentials have earned the compulsory credibility necessary
to educe cooperation from individuals with relevant and reliable
information. Above all, we are committed to the axiomatic norms of
professionalism. We believe in professionalism, integrity and ethical
conduct in our relations with those we serve.
We provide services through out the entire Hawaiian
Islands and the Pacific Region. Call us Toll free at (800) 306-6682 or
(808) 732-6999.
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The
Bureau of Private Investigation's is a Full Service
Investigation Company. Including access to an accredited private
Forensic Laboratory for DNA Y-Chromosome testing, Forensic Serology
& DNA analysis, Human Identification, and Paternity testing.
As a full service Agency, we can
customize investigations to meet your needs and budget.
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are not only the leaders in the field of Private Investigation and
set the example in Professionalism but we train others as well.
Check out our PI School.
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