What is the Legal Definition of Workers’ Compensation Fraud in California?

Workers’ compensation fraud is a serious issue. The California Department of Insurance estimates that fraud within the workers’ compensation system costs the state between $1 billion and $3 billion each year. This raises an important question: How is workers’ compensation fraud defined? Our Fresno workers’ compensation defense law firm answers the question by providing a guide to the legal definition of workers’ compensation fraud in California.

Know the Statute: Workers’ Compensation Fraud in California

Under California law (California Insurance Code § 1871.4), a person or entity commits workers’ compensation fraud if it does any of the following four things:

  • Make or cause to be made a materially false or misleading statement for the purpose of getting or denying workers’ compensation benefits;
  • Present or cause to be presented knowingly false documents or statements in workers’ compensation proceedings;
  • Knowingly assist or conspire to help another party improperly obtain or deny workers’ compensation benefits; or
  • Make or cause to be made false or misleading statements to discourage a worker from filing for workers’ compensation benefits.

Examples of Workers’ Compensation Fraud in California

Workers’ compensation fraud can come in a wide range of different forms. It could be committed by an employee, a medical provider, an employer, or even an insurance carrier. Some of the most common examples of workers’ compensation fraud in California include:

  • A False Claim by an Employee: As an example, someone might claim they hurt their back on the job, but actually, they had the injury from a weekend recreational sports game. They might do this to get paid time off or to receive money from the workers’ compensation insurance benefits in violation of the law.
  • An Exaggerated Injury by an Employee: With this type of case, an employee does get hurt at work, but they make the injury seem worse than it really is. For example, someone might have a minor fall that only causes a slight sprain. However, they tell their doctor and employer that they are in extreme pain and that they cannot work at all.  
  • Improperly Billed Service by Medical Provider: In some cases, the fraud comes from the medical provider, not the employee. A doctor or a clinic might treat an employee for a workplace injury and then charge the insurance company for services they never provided or for more expensive services than what was given.
  • Underreporting Payroll by Employer: Employers can also be guilty of workers’ compensation fraud. Most often they do this by lying about how many people they employ or how much they pay them. For instance, a business owner might report that they have fewer workers than they actually do in order to reduce their workers’ compensation premiums.

Get Help From Our Fresno, CA Workers’ Compensation Defense Lawyer Today

At Yrulegui & Roberts, our Fresno workers’ compensation defense attorneys provide the solutions-focused legal advocacy that employers and insurers can count on. If you have questions or concerns about handling a workers’ compensation fraud matter, please do not hesitate to contact us today. We provide workers’ compensation defense services in Fresno and across the region.