Workers’ Comp Fraud

Workers’ Comp Fraud is insurance fraud to obtain workers’ comp benefits, such as medical care and wages lost as a result of a job site injury.

Prosecuting Workers’ Compensation Fraud 

Prosecuting Workers’ Compensation Fraud CA Insurance Code 1871.4

This crime may be charged as a felony or as a misdemeanor, depending on the specific instance. It is considered fraudulent if you:

1. Knowingly provide false material statements to obtain or deny workers’ comp benefits;
2. Discourage a potential Workers’ Compensation benefits recipient from claiming benefits or pursuing a claim by making false statements about his or her eligibility for benefits; or
3. Knowingly aid/abet or conspire with another to commit an act of workers’ compensation fraud.

False Statements

Statements include any representations of fact, such as oral or written words, bills, payments, etc. Material statements are those that are related to the investigation of the claim and are direct and important to such investigation. False statements are those that are either not true or intended to get another person to act to his or her detriment.

Was it Fault?

Workers’ compensation fraud is a “no-fault” system, meaning the injured worker need not prove anyone was at fault or committed an act of wrongdoing in order to receive benefits.

Prosecuting CA PC 550

In order for the prosecutor to prove that you’re guilty of workers’ compensation fraud as the employee, he/she must prove the three elements of the crime:

1. You knowingly made or caused another to make a false claim for benefits covered by workers’ comp insurance;
2. You knowingly submitted such a claim that was not in fact used by the person claiming benefits; or
3. With intent to defraud, you knowingly presented multiple claims for benefits of the same workers’ comp benefit.

Prosecuting CA Penal Code 549

In order for the prosecutor to prove that you’re guilty of workers’ compensation fraud as the business owner or employee, he/she must prove:

1. You solicited, accepted, or referred business to or from another person or entity; and
2. You did so with knowledge or reckless disregard for whether the person or entity actually had the intent to commit workers’ compensation fraud.