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Workers' Compensation Insurance Fraud Information

Worker climbing onto a large tractor

The consequences of insurance fraud are serious. If convicted, penalties may include the following:

  • Up to five years in jail
  • Up to $150,000 in fines
  • Loss of a professional license
  • Conviction of insurance fraud can have collateral consequences

Information for Employers

Workers Compensation fraud is a local and statewide issue negatively impacting industry, employers, the medical profession and local businesses. Approximately $10 billion in workers compensation claims are filed every year in California. It is estimated that up to 30% of these claims are fraudulent. We’re here to assist employers with ways to reduce fraud in the workplace.  The Sonoma County District Attorney’s Office is committed to enforcing workers compensation laws. Those who commit fraud are subject to criminal prosecution.

Penalties may include up to 5 years in jail and up to $150,000 in fines. Our goal is to ensure that Sonoma County continues to be a place where honest businesses thrive.

Be aware of red flags or suspicious activity following a work-related injury

  • Was there an unexplained unreasonable reporting delay of the injury by the employee?
  • No witnesses to the injury?
  • Did the injury happen at an odd time (break or lunch, etc.) or in a location where the employee wasn’t supposed to be?
  • Have you had difficulties reaching the employee at home while they were supposed to be off work due to an injury?
  • Is there an unusual coincidence between the employee’s alleged date of injury and their need request for personal time off?
  • Do you have suspicions regarding weekend activities that could explain the “first thing Monday"?
  • Does the employee play sports, have hobbies or engage in activities similar to what could have caused the work injury?
  • Does the employee have preexisting medical conditions similar to the work injury?
  • Does the employee do volunteer work or have another paying job?
  • Does the employee have a history of short-term employment?
  • Is the employee disgruntled, soon-to-retire or facing imminent dismissal?
  • Does the employee protest a physician-approved return to work?
  • Do the employee’s injuries never seem to improve?
  • Have friends or co-workers seen the employee engaged in activities off work that are restricted while at work or while on leave?

Steps to take when an employee makes a claim

Investigate immediately

You should investigate all injuries and claims thoroughly. While memories are fresh, talk to each witness separately and ask each one what they know about the injury/incident. After investigating discuss your findings with the claims adjuster and be sure to relay any suspicions of fraud.

Prepare for a smooth return to work

Keep in touch with the injured employee and tell them they will be welcomed back to work when their doctor approves it. Employees who feel valued are less likely to abuse the system.

Never deny or confirm suspicious claims

You may receive phone calls or letters from medical or legal professionals asking you to verify injuries you feel are suspicious. Refer ALL questions directly to your insurance carrier without discussion, because anything you say could be used to legitimize unnecessary medical or legal services.

Information for Employees

Workers’ compensation is a benefit provided to employees who are injured on the job. ALL employees, regardless of residency status, may be entitled to workers’ compensation benefits if they are injured on the job. 

Employers must carry workers’ compensation insurance coverage or certify that they are self-insured through the State of California.   It is illegal for an employer to operate without workers’ compensation insurance.  (California Labor Code Section 3700.5)

Claim Discouragement

It is illegal for an employer or his agents, such as supervisors or foremen, to misrepresent, deny or discourage an injured worker from seeking or receiving workers’ compensation benefits. 

(California Insurance Code Section 1871.4)

It is illegal for an employer to offer incentives or threaten and discourage workers from making a workers’ compensation claim.

Fales or Fraudulent Claims

It is illegal for a worker or employee to make or file a false or misleading injury claim.  Penalties for fraudulent claims are serious.

Deliberate exaggerations or willful lies about how the injury happened or the nature or extent of the injury may be workers’ compensation fraud.

Red flags if You Are Injured on the Job

If your employer does any of the following after you have been injured at work, notify the District Attorney’s Office:

  • Asks or tells you to tell the hospital or treating physician the injury did not happen at work
  • Asks or tells you to use your own health care insurance to cover your work-related injury
  • Asks you to tell the hospital or treating physician that the employer is self-insured and will pay the expenses directly
  • Tells you to pay for the medical treatment and they will reimburse you
  • Makes promises or assurances to pay you for your injuries if you cooperate
  • Does not give you information or the forms necessary to file a claim
  • Threatens to fire you or adversely affect your employment or immigration status if you file an injury claim.

If your supervisor, foreman, or employer refuses to provide medical care, refuses to provide assistance with necessary claim paperwork following a work-related injury, offers you incentives NOT to report the injury as work-related, or any of the previously listed red flags, you may:

  • Seek medical help and tell the physician and/or hospital that your injury is work-related
  • Provide your employer’s identifying information, name, business name and address and any applicable license numbers to your medical provider
  • Make note of the names and contact information for any witnesses who are aware of your employer’s refusal to provide you with assistance or forms, or offers of incentives or threats of retaliation
  • Notify the Sonoma County District Attorney’s Office immediately.

RETALIATION AND DISCRIMINATION

 It is illegal for an employer to fire, threaten to fire, or in any way discriminate or retaliate against a worker who states their intention to file a workers’ compensation claim or has already filed a workers’ compensation claim. It is also illegal to retaliate or discriminate in any way against a worker who has received a workers’ compensation injury rating, award or settlement. 


Frequently Asked Questions

Q:  What are the most common criminal charges for insurance fraud?
 
A:  Most prosecutions of insurance fraud allege one or both of the following:
·  Penal Code section 550
·  Insurance Code section 1871.4
 
 
Q:  Are there any other agencies or department where I can find more information?
 
A: Yes, 

California Department of Insurance (CDI)
http://www.insurance.ca.gov/
800-927-HELP (4357)
 
California Department of Industrial Relations (DIR)
http://www.dir.ca.gov/
 
National Insurance Crime Bureau (NICB)
https://www.nicb.org/
847-544-7002
 
 
Q:  How does insurance fraud effect the community?
 
A:   Insurance Fraud totals over $15 billion each year, which is an average of $500 a year per resident of California.  This results in higher premiums, higher taxes, and higher prices.  Insurance fraud is the second most costly crime in the country.  The impact of insurance fraud has a direct effect on a communities’ residents.  Click here for more information on the effect of insurance fraud.