GQ Corner
Q. I have a claimant that returned to work making full wages, but continued to advise me that he was still not working. Because the claimant received and cashed the checks knowing that he was working, is the carrier allowed to pursue fraud?
A. The PLN-2 indicates that the claimant should contact the adjuster if he is earning money from any work. The rest of the language on the PLN-2 anticipates that the employment is with someone other than the insured, but the fact that it includes the language, “You start earning money from work” means that it would include earning money with the insured. Rule 129.4 does not specifically require the claimant to report earnings unless it is from an entity other than the insured, but fraud under Sec. 415.008 provides that the claimant commits an Administrative Violation if the person obtains payment of workers’ compensation benefits by knowingly or intentionally misrepresenting a material fact or concealing a material fact.
Q. I have received a claim for mental stress. The claimant states that the threat of termination from a new manager led to stress from continuously working odd and extensive hours, which led to sleep deprivation. Additionally, he stated that he was berated and demeaned to the extent that he attempted to intentionally overdose on his ADHD medications. Following this attempt, he was held at an in-patient psychiatric ward for 10 days. Am I able to deny this claim?
A. You have a reasonable basis to deny this claim because the attempted suicide, due to ongoing stress, is the claimed injury secondary to repetitive mental trauma, and it is neither an occupational disease nor compensable. Furthermore, there is insufficient evidence of an undesigned, untoward event traceable to a definite time, place and cause as to establish an accidental mental trauma injury. Transportation Ins. Co. v. Maksyn, 580 S.W.2d 334 (Tex. 1979). Additionally, the claimed mental trauma injury is not compensable insofar as it arose principally from a legitimate personnel action under Texas Labor Code Section 408.006(b).
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