Californias employers must maintain Workers Compensation Insurance coverage for their employees. The system exists to create a mechanism for employees to receive treatment and compensation for injuries which occur on the job. The system is expensive for employers who have faced premium increases in recent years. There is huge fraud in the system, and the Orange County District Attorneys Office maintains a vertical unit devoted to prosecution of crimes involving fraud in Workers Compensation Insurance.
There are many different kinds of Workers Compensation Insurance fraud. Applicants commit fraud if they make a false or fraudulent statement in connection with a claim or wrongly claim injury if there is none. Employers commit a crime if they fail to maintain coverage for their employees or falsely classify or count employees in order to obtain a cheaper premium. Medical and legal professionals who employ cappers to solicit patients/clients who are not truly injured can be charged with fraud for paying for referrals and providing unnecessary treatment or billing for treatments that are not provided. Insurance company employees can be charged with fraud for deceptive activity involving claims.
Insurers or third party administrators for self-insured employers are required to report suspected fraud to both the California Department of Insurance and the Orange County District Attorneys Office. The standardized form for reporting suspected fraud is available on the Department of Insurance website at www.insurance.ca.gov. Those who report suspected fraud should fill out the form completely and enclose documentation that they may have.
Fraudulent claims are generally investigated by the California Department of Insurance and submitted to the District Attorneys Office for filing determination.
