Employers recognize the risks associated with their work, so they purchase workers’ compensation coverage. The insurance compensates workers who sustain injuries or develop work-related illnesses for medical treatment and the income lost for the duration they have been away from work.

Workplace injuries or illnesses happen; when they do, you are eligible for compensation from your employer’s policy. Sadly, you could face workers’ compensation fraud while pursuing your rightful damages. The charges happen when authorities accuse you of submitting a fraudulent claim to obtain illegal insurance benefits. The crime is associated with detrimental penalties. You should avoid a conviction by all means. At the California Criminal Lawyer Group in Bakersfield, we can craft viable defenses to assist you in contesting the allegations.

Composition of Workers’ Compensation Fraud

In many ways, the prosecutor can charge and secure a guilty verdict for workers’ compensation fraud. It could be because you presented a false statement to repudiate or acquire unlawful insurance gains. Many employers make fraudulent or deceptive declarations on worker eligibility for insurance benefits to deter injured employees from obtaining compensation or to aid them in acquiring illegal benefits.

Also, the court is likely to issue a guilty verdict against you if there is proof to show beyond moral certainty that you prepared and presented numerous claims seeking multiple perks for the same injury or illness. An employee eligible for the benefits seeking compensation for medical treatment that they did not use also amounts to fraud. Medical practitioners or facilities that beg, accept, or refer business while aware that the person offering the business intends to commit fraud are also guilty of the crime.

Doctors, pharmaceutical companies, employers, businesses, and workers can face fraud charges contingent on the California statute they are accused of violating. If you want to understand this form of charge or face the charges, it is crucial to familiarize yourself with these statutes.

California Insurance Code (IC) 1871.4

The primary statute prescribing workers’ compensation fraud in the state is IC 1871.4. You violate this law as an employee when you make or help another party make a misleading representation to reject or receive workers’ compensation perks. Also, you breach this statute when you submit or cause another party to submit deceptive oral or inscribed material to support or oppose a compensation claim. A violation of IC 1871.4 also happens when you aid or back the commission of fraud.

Employers must purchase workers’ compensation coverage from private insurers. The insurer pays for the medical treatment when eligible workers suffer on-the-job injuries. If the injuries cause temporary incapacity that prevents the worker from going to work and earning an income, the insurer pays for the lost earnings or wages. These are estimated based on when the employee has been recovering from work.

Some work-associated illnesses or injuries cause permanent disabilities and prevent employees from ever returning to work. Under the circumstances, the employee is eligible for current and future lost wages and earning capacity. The court considers the worker’s age, remaining years until retirement, and current wages to estimate appropriate compensation.

Other times, workers die because of work-linked injuries. In these cases, the deceased’s estate or descendants receive the insurance benefits.

You must know that workers’ compensation perks are only available for injuries at the workstation or when performing a task for the employer's benefit. You cannot pursue an insurance claim for an underlying illness unrelated to your job. Also, injuries sustained away from work or outside the scope of your employment are ineligible for compensation.  Again, it would be best to understand that after you file a claim, you lose the right to sue your employer in court for personal injuries sustained at the workplace.

However, a workers’ compensation claim differs from a personal injury one. In workers’ compensation claims, the statute does not necessitate you to demonstrate that another party’s negligence or fault was the cause of your injuries. The insurance scheme adopts a no-fault doctrine, eliminating the need to prove someone else caused your injuries. You will also receive benefits without having to show that you suffered damages. The law only requires that you prove the injuries stemmed from the job to obtain compensation.

Meaning of a Representation

The prosecutor secures a guilty verdict when they demonstrate that your representation of a claim was misleading or fraudulent. The representation refers to:

  • A jotted or oral statement from you, the claimant.
  • An injury notice.
  • Any evidence of injury.
  • Invoices for services paid for because of the injuries.
  • Proof of payment for the services.
  • A doctor’s report.
  • Medical test results.

A representation is deemed “material” when it conveys the requisite relevant details on a topic that can sway the insurer’s investigations into the claim. Any statement that influences the review or inquiry into a claim is deemed “material” by the law.

For example, years ago, you were in a vehicle accident that caused back injuries. You were treated for the injuries and recovered, but from time to time, you experience back pain. One day, while on duty, you slip and fall. You will seek compensation if the back is hurt again because the second back injury is work-related. However, in your claim, you fail to mention that you previously sustained back injuries that happened in an incident away from work. 

If you had notified your employer, doctor, or insurer about the previous damage, it would be factored in when estimating your insurance benefits. Knowledge about the harm could have caused the insurer to deny you benefits, or the perks you are entitled to could have been reduced considerably. From this example, you can deduce that it was “material” to disclose previous back injuries during investigations. Withholding the details from the investigators amounts to fraud and attracts criminal charges under IC 1871.4 and a possible conviction.

Definition of Fraudulent or Misleading

You cannot face arrest or criminal charges for defrauding workers’ compensation if you submit facts in your claim. You only risk charges and conviction if the facts of a statement or information you disclose during the claim investigation are untrue. The law criminalizes withholding or concealing facts to persuade another party to act wrongly.

False declarations are prevalent in these fraud cases and attract criminal charges. These fraudulent statements include:

  • Faking an injury or illness.
  • Denying the fact that you filed claims in the past.
  • Lying about injury extent by depicting minor injuries as significant.
  • Asserting that your disease or harm is work-related when it is untrue.
  • Illegally continuing work will obtain workers’ compensation perks.
  • Receiving damages for your illness or harm from different employers.
  • Concealing material facts of a previous injury.

Employees are not the only defendants who face charges under this law. Employers face these charges when they give misleading statements about workers’ compensation indemnity. As an employer, you risk these criminal charges when you lie to an insurance provider about the number of workers at your workplace. Also, lying about an employee’s job title or misrepresenting their duties is fraud. Lying about the insurance benefits scope or discouraging a worker from obtaining benefits amounts to fraud by employers.

For example, you own a company, and one of your workers sustains injuries while performing work duties. You decide to prevent the worker from seeking workers’ compensation by lying that they are not eligible for the perks because they have only been on the job for a short time. New employees are also qualified for the benefits because they are still company employees, which makes your statement about the injured worker not being eligible for insurance benefits false. If you make a fraudulent statement like this and a worker is discouraged from seeking reimbursement, you risk possible charges and a guilty verdict for fraud.

Whenever a worker claims compensation, insurance providers increase the premiums, which many employers are against, which is why they discourage employees from seeking compensation.

California PC 550

Several fraud crimes that intertwine with healthcare fraud are outlined in PEN 550. Under the statute, it is unlawful to:

  • Deliberately make or enable the submission of a misleading claim to obtain healthcare compensation payment provided for under workers’ compensation coverage.
  • Consciously claim health insurance benefits provided for under workers’ compensation when the benefits are unused.
  • Knowingly file numerous claims for similar workers’ compensation healthcare gains.

Different players can face counts under this law. Workers, employers, and medical experts can all engage in the crime. Medical care providers collaborate with employers or employees to defraud insurance providers.

For instance, as a doctor, you can claim to have provided medical services when a worker has not obtained any treatment.

Medical practitioners found guilty of a PC 550 violation face severe consequences because their professional licenses are revoked. Additionally, they face the standard penalties for the offense.

PC 549

Company owners and workers can all face charges for breaching PEN 549. A breach of the statute happens when you refer, accept, or lobby for business from particular individuals or entities. The prosecutor will secure a guilty verdict if they demonstrate that you were aware that the organization or party had motives for perpetrating workers’ insurance fraud.

Chiropractors, physicians, and other medical service providers commonly face these allegations when they deliberately engage in commercial corruption or kickbacks from profits tailored to defraud the insurance scheme.

For example, you operate a business that produces prescription pain medications. You pay kickbacks to physicians and chiropractors for them to prescribe the medicines to their clients, all receiving medical care under workers’ compensation coverage.

Because of the technical information about how insurance providers compensate ingredients, insurers overpay you colossal amounts for the painkillers, not knowing they are being defrauded. Under the circumstances, the medical professionals you pay kickbacks from profits to prescribe the medication are guilty of a PEN 549 violation because they disregarded or ought to have known you were committing workers’ compensation fraud.

Workers’ Reimbursement Insurance Fraud Penalties

The penalties and disabilities associated with a conviction for compensation fraud hinge on the statute you are alleged to violate. For instance, when you face charges under IC 1871.4, you risk misdemeanor or felony counts because the offense is a wobbler. The count they prefer depends on your crime’s nature and criminal history.

When the prosecutor prefers misdemeanor charges, a guilty verdict will lead to:

  • Summary or informal probation.
  • Jail incarceration of at most twelve months.
  • Colossal court-imposed financial fines of at most $150,000, or twofold the fraud sum, whichever is greater.
  • Victim restitution entails compensating the victim the money they lost due to the fraud crime.

If the district attorney (DA) charges you with a felony count and they secure a guilty verdict, the penalties will be as follows:

  • Felony or formal probation involves regular meetings with the supervising or probation officer, which continue for 36 to 60 months.
  • Jail incarceration for 24, 36, or 60 months under realignment.
  • Financial court monetary fines of at most $150,000 or twofold the fraud figure, based on the higher one of the two.
  • Victim restitution for the losses.

PC 550 Penalties

When the fraud crime concerns health insurance fraud, the prosecutor brings charges under PEN 55o, which is also a wobbler. A guilty verdict for a misdemeanor under this statute attracts:

  • Misdemeanor probation.
  • Twelve or fewer months in county jail.
  • Financial court financial fines of at most $10,000, together with or in place of the jail term.

A felony conviction attracts:

  • 36 to 60 months of formal or felony probation.
  • Jail incarceration for 24, 36 or 60 months.
  • $50,000 in court fines or twofold the fraud figure, depending on which of the two is greater.

You must understand that the statute has an exception when the fraud figure is less than $950, including many claims made consecutively within a year. Under these exceptions, a PEN 550 violation is always filed as a misdemeanor that attracts no more than six months of incarceration and financial court monetary fines of no more than $1,000.

Penalties for a PC 549 Violation

The fraud offense is a wobbler if it is your first time violating PEN 549. However, for repeat offenders, the offense automatically becomes a felony. A misdemeanor guilty verdict attracts at most twelve months of jail incarceration and a court financial fine amounting to $50,000, or twice the fraud figure, based on the greater amount of the two.

A felony sentence attracts 16, 24, or 36 months of county prison incarceration. Besides, the court can order you to pay a court fine like that imposed for a misdemeanor PEN 549 breach.

Workers’ Compensation or Reimbursement Fraud Civil Penalties

On top of the standard consequences for workers’ compensation coverage fraud, you also risk civil penalties contingent on the type of fraud. You risk civil consequences when you knowingly misrepresent facts to obtain coverage at a rate less than the one provided by the law. The fraud type is prevalent among workers. You also risk a civil case when you submit or cause the submission of a fraudulent representation in favor of or against an insurance compensation claim. Also, you risk civil action if you make a misleading statement to deny a genuine claim.

Similarly, you risk civil charges when you knowingly offer profit-oriented services that entail advising injured workers on healthcare services provided under the workers’ compensation scheme. You risk civil charges when you conspire to help another party commit fraud.

The penalties for a civil count include:

  • A civil penalty ranging from $4,000 to $10,000 for every illegal workers’ compensation claim.
  • Penalty evaluation fee no more than thrice the medical-valid expenses sustained by the insurance provider due to the fraud.

Besides, when you commit another fraud while having a prior IC 1874.1 or PC 549 violation conviction, you risk additional civil consequences. The penalty includes at least $4,000 for items acquired falsely.

Professional Discipline

A guilty verdict for workers’ reimbursement fraud can trigger professional disciplinary action. If the guilty verdict relates to your professional duties, you risk disciplinary action, with the most severe being a total revocation of your professional license, meaning you will never practice again. Medical practitioners and pharmacists are the ones who commonly face these disciplinary actions.

Contesting Workers’ Compensation Fraud Charges

The insurance department in California and the district attorney’s (DA) office are putting a lot of resources into revealing or exposing fraudulent insurance claims, as the cases are increasing alarmingly. Investigative units conduct stings and undercover surveillance to catch individuals engaging in insurance fraud.

With the heightened vigilance and political motivation, the authorities rush investigations and end up charging and wrongfully convicting innocent persons. Many wrongful convictions happen to individuals who are not lawyered up. Therefore, when you face these allegations in Bakersfield, do not hesitate to contact the California Criminal Lawyer Group to contest the accusations and protect your rights. Your legal representative will evaluate the case and craft legal defenses based on your circumstances. The valid defenses against the accusations are:

  1. Lack of Intentions to Defraud

The court cannot convict you of workers’ compensation fraud unless the prosecutor can prove that you were aware your presentation was fraudulent. When making the misleading statement, your motive must have been to defraud the insurance provider. Insurance investigators can point out a blunder or error in your submission as a fraud attempt and report the issue to the police. However, because of the high evidentiary standard in criminal cases, it becomes difficult for the prosecutor to show beyond moral certainty that you were aware you were engaging in fraud. In these situations, your attorney will poke holes in the prosecutor's evidence to put doubt in the jury's minds about the offense and negotiate a count reduction.

  1. Insufficient Proof

Workers’ compensation fraud normally involves complicated facts that are difficult to interpret or decipher. The evidence can seem impressive when the prosecutor receives the paperwork, but it can fail to meet the evidentiary standard once it is evaluated in court. Your attorney will exploit that ambiguity cannot be used to secure a conviction and point out that the DA lacks the evidence threshold required for a fair conviction. Also, the lawyer should gather solid evidence to show that you did not commit the crime and prevent an unjust conviction. That way, the court will lower the charges or drop the case entirely.

  1. The Misleading Information was not Material

Even when you deliberately submit a misleading representation to defraud workers’ compensation coverage, you will not be guilty if the details are not material (relevant) to the claim approval or increase in claim figure.

Related Crimes

Several offenses are filed with workers’ reimbursement or compensation fraud. These include:

Grand Theft

Workers’ insurance fraud regularly intertwines with grand theft, as prescribed under PEN 487. Per the statute, obtaining another party’s property worth at least $950 without permission is a crime. One form of grand theft that fits the insurance fraud definition is theft by false pretenses.

A misdemeanor conviction for grand theft attracts no more than twelve months of jail incarceration, while a felony attracts 16, 24, or 36 months.

California Forgery

Per PC 470, forgery is engaging in the following acts with fraudulent intent:

  • Signing another party’s name.
  • Faking an individual’s handwriting or seal.
  • Amending or fabricating legal documents.
  • Altering or submitting a fraudulent financial document as genuine.

Therefore, when, for instance, you falsify a physician’s signature on a medical report to claim workers’ compensation benefits, you can face an insurance fraud charge and forgery.

The penalties for forgery are the same as those for grand theft.

California Perjury

PEN 118 defines perjury as intentionally giving misleading information under oath. You risk perjury and fraud charges when you knowingly lie in an informal declaration or during deposition while being investigated for defrauding or an attempt to defraud the workers’ compensation scheme.

Perjury is a felony with a possible prison sentence of 24, 36, or 48 months upon conviction.

Find a Skilled Fraud Crimes Lawyer Near Me

The disabilities associated with a workers’ compensation insurance fraud conviction can be detrimental. Similarly, some allegations are based on misunderstandings or false allegations. Without proper representation, you could be unjustly convicted and face harsh penalties. At the California Criminal Lawyer Group in Bakersfield, we know the complexity of these fraud crimes and the need for legal representation. Therefore, contact us at 661-750-8230 to evaluate your case and craft defenses.