Office of the District Attorney
DA Tip Line
1-800-556-0027
2. Most common types of Worker's Compensation Fraud
c. Employer and Insurance Carrier Fraud
e. Claim Mills
3. Important Facts Employees Should Know
4. Important Facts Employers Should Know
The Tehama County District Attorney’s Office in conjunction with the California State Department of Insurance will investigate and prosecute workers’ compensation fraud cases occurring in Tehama County. Workers’ compensation fraud crimes are generally felonies and are punishable by sentencing to state prison. The Tehama County District Attorney’s Office may investigate these crimes independently or these crimes may be investigated by the State of California Department of Insurance.
Workers’ compensation fraud poses a huge problem in the State of California. Over a billion dollars of fraudulent claims are paid out yearly in California. This type of crime causes major insurance costs increases to employers and their companies. These costs have forced companies to go out of business or move their companies out of state.
Fraudulent claims have also undermined the integrity of the system. This causes legitimate claimants to possibly have delays in treatment of real injuries and the processing of their legitimate claims.
Workers’ compensation fraud is committed by employees, employers, doctors, lawyers and insurance companies. Fraud occurs in both the private and public sectors. Everyone suffers because of workers’ compensation fraud. Tax dollars are wasted, the price of consumer goods increase and legitimately injured workers and the people who employ them loose money.
Workers’ compensation fraud effects almost all Californian’s in one way or another and is a serious and expensive problem. Tehama County District Attorney, Gregg Cohen, encourages anyone that believes they might have any information about a workers’ compensation fraud, contact the District Attorney’s Bureau of Investigation at (530) 529-3590 or by calling the Tehama County District Attorney’s workers’ compensation fraud 24-hour Hot Line at 1-800-556-0027.
MOST COMMON TYPES OF WORKERS’ COMPENSATION FRAUD
These cases involve workers who fake an injury, lie about the effects of their injury, lie by denying filing previous claims, fail to disclose a previous injury to some body part, claiming a non-work injury as work related, illegally working while obtaining workers’ compensation benefits.
Premium fraud occurs when employers fraudulent misstate their number of employees or the nature of their work, such as reporting a tree trimmer as an officer worker. Some companies carry no workers’ compensation insurance at all. Under current California Law, workers’ compensation fraud units can now prosecute uninsured employers.
EMPLOYER AND INSURANCE CARRIER FRAUD:
In this type of fraud, employers or employees of an insurance company will make a false statement regarding a worker's entitlement to their benefits. These statements are designed to discourage the worker from pursuing a legitimate claim.
Regardless of the legitimacy of the original claim, many medical and other health practitioners fraudulently maximize the number of medical reports and referrals in each case to increase the number of billings. They may also over bill or render unnecessary treatment.
Organized workers’ compensation fraud involving doctors and lawyers have been an on-going problem in California. Fraud rings have made a practice of recruiting people to file phony work injury claims. The workers are sent to medical or legal referral centers commonly known as “claim mills” which in turn refer them to a doctor or lawyer who is in on the fraud scheme.
IMPORTANT FACTS EMPLOYEES SHOULD KNOW ABOUT WORKER'S COMPENSATION:
· If you get hurt on the job, your employer is required by law to provide workers’ compensation benefits.
· If the injury is a medical emergency, go to an emergency room immediately. Tell the health care provider treating you that your injury or illness is job related.
· Report any work-related injury to your supervisor immediately or as soon as possible. If the injury or illness developed gradually (such as tendonitis or hearing loss), report it as soon as you learn it was work related.
· If you get hurt on the job, medical care must be paid for by your employer, whether or not you miss time from work.
· You may be eligible to receive benefits even if you are a temporary or part time worker.
· You may be covered by workers’ compensation even if you are called an “independent contractor.”
· You don’t have to be a U.S. citizen to receive workers’ compensation benefits.
· You receive benefits no matter who was at fault for your work-related injury.
· If you are unable to return to your job due to a work related injury, you may qualify for vocation rehabilitation.
· It’s illegal for your employer to punish or fire you for having a job related injury or for requesting workers’ compensation benefits when hurt on the job.
IMPORTANT FACTS EMPLOYERS SHOULD KNOW ABOUT WORKER'S COMPENSATION:
· California law requires employers to have workers’ compensation insurance. Even out-of-state employers may need workers’ compensation coverage if a contract of employment is made in California.
· The California Code of Regulations requires all employers to have an Illness and Injury Prevention Program.
· The cost of workers’ compensation insurance is the employer’s responsibility. The employer cannot legally require an employee to pay for any of the coverage including out-of pocket medical expenses.
· Safety and health training must be conducted in a forum readily understood by all employees. Written and verbal instructions must be provided in the employee’s primary language.
· Information regarding workers’ compensation coverage and where to get medical care for work related injuries must be posted in the workplace.
· Employees must be told they have a right to pre-designate their personal physician to treat a work-related injury.
· The employer must provide the injured employee a claim form (either personally, or by first class mail) within one working day of knowledge of a work-related injury.
· Employers have one working day after the claim form has been returned to complete their portion and forward it to their insurance company.
· If an employee claims to have been injured at work, but you feel it’s a false claim, you still need to complete the required forms. You should document your concerns in writing to the insurance company. The insurance company will make a decision and notify the employee.
· Minimize reoccurrence by investigating and analyzing all accidents. Identify and correct any hazards. Maintain complete records, including statements of witnesses. Emphasize prevention, not fault.