When workers lose income due to injuries suffered while working, they are entitled to workers' compensation according to California law. Workers' compensation is a form of insurance that offers medical care and compensates workers for lost income. If you commit workers' compensation fraud in California, you might face criminal charges. The associated criminal penalties for committing workers' compensation fraud are detrimental. The LA Criminal Defense Law Firm assists defendants in Los Angeles who are facing workers' compensation fraud to come up with a proper defense strategy. 

Ways of Committing Workers Compensation Fraud

You can commit workers' compensation fraud in various ways. You might be guilty if you present a fraudulent or false material statement to deny or obtain workers' compensation fraud illegally. It is common for people to make a fraudulent or misleading statement on the qualification and eligibility for workers' compensation benefits. The main aim of the deceptive statements is to prevent injured workers from claiming their benefits.  You might face fraud charges if you aid, abet, or take part in a plan to commit workers' compensation fraud. 

If you intentionally prepare and submit numerous insurance claims seeking payment of health care benefits, you might be guilty of workers' compensation fraud. It is against the law to file several claims seeking several compensations for a single injury.  A worker may apply for medical care benefits that he/she did not use; this is a form of workers' compensation fraud. It is illegal to refer, solicit, or accept any business or trading from an individual knowing that he/she has an intention to commit workers' compensation fraud. 

Laws that Relate to Workers Compensation Fraud in California

The primary statute outlining workers' compensation fraud is California Insurance Code 1871.4. You might violate the Insurance Code 1871.4 if you make or you false the making of a false statement or a false representation to deny or obtain workers' compensation benefits.  You might also present, or you cause the presentation of a fraudulent or misleading oral or written material in support or opposition to workers' compensation benefits.  If you aid or you abet another person to commit workers' compensation fraud, you will violate Insurance Code 1871.4.

The law requires all employers in California to cater to private insurance. If an employee suffers injuries while working, the private insurer will compensate the employee; the employee may receive compensation for medical care. If the employee suffers a temporary disability and is unable to work, he/she is entitled to compensation.  The compensation upon suffering temporary disability includes payment for lost income/wages for the period when the worker is not able to perform work duties while recovering. 

After suffering injuries in the workplace, a worker may not be able to go to work for a lifetime. In this case, the worker would be entitled to compensation for lost income/wages for the remaining period of employment. Some of the factors that may determine the compensation the worker receives are the age of the worker and the remaining period to retirement. 

A worker may succumb to the injuries suffered in the workplace. In case of death, the insurance company pays death benefits to the surviving relatives of the worker.  The insurer may pay benefits to the spouse, children, and other surviving dependents of the worker.

You can only seek workers' compensation for the injuries you suffer in the workplace or while in the course of duty. You cannot seek reimbursement for pre-existing medical conditions. You cannot also seek compensation for injuries you suffer away from the place of work.  It is important to note that injured workers face a limitation when requesting workers' compensation. Workers cannot sue/file a lawsuit against their employer in California civil courts in California when seeking compensation injuries suffered while working. 

Unlike when seeking compensation in California personal injury cases, workers' compensation benefits do not require you to prove that another person caused the injury. Workers' compensation relies on a no-fault legal system. This implies that a worker has no obligation to confirm that the injuries are a result of another person's fault. You will still receive compensation even if you do not prove that another person is responsible for your damages.  As long as you suffered the injury in the workplace or while in the line of work, you qualify for compensation. 

A Fraudulent Representation or Statement

You are guilty of committing workers' compensation fraud if you make a fraudulent or false statement regarding workers' compensation. The representation or statement should aim at allowing or denying workers compensation to an employee. In the context of California law, false representation or statement comprises a written or an oral representation or statement by the claimant.  Other types of representations and statements include issuing a fraudulent notice, false proof of injury, or fraudulent bill for services. Other forms of fraudulent statements and representations include fraudulent doctor and hospital records, false test results, or x-ray results. Any fraudulent form of evidence of injury, expense, loss, or payment, including false proof of medical-legal costs, may lead to workers' compensation fraud charges. 

A statement or representation qualifies as material if the statement conveys/passes the information on a subject, and the information is reasonably relevant or may influence the insurance company's investigation of the compensation claim. If the information may count in the evaluation or the investigation of a worker's compensation claim, the information is material.

Fraudulent or False Information

If you present facts relating to a worker's compensation claim, you cannot face fraud charges. You only face fraud charges if you make fraudulent or false statements regarding a claim.  A fraudulent or false statement refers to an untrue statement. It is illegal to conceal material facts aiming at inducing an individual to act to his or her detriment. 

You might make a fraudulent or false statement if you fake an injury. For instance, you might claim to have suffered an injury in the place of work, yet it is not true. It is also illegal to lie about the extent of the injury. Lying about the scope of the damage entails exaggerating; for instance, you might depict a minor injury to be significant. You might make a fraudulent or false statement if you make a false claim. You may claim to have suffered an injury at work or in the line of duty, yet the damage is non-work-related.  You might also make a false statement if you claim to have suffered an injury in the workplace, yet the injury was pre-existing.  If you collect compensation for the same injury from different employers, you might be guilty of making a false statement. You might also make a fraudulent or false statement if you deny having filed previous claims.  A worker may also be guilty of making a false statement if he/she illegally works while at the same time receiving workers' compensation benefits. 

Just like employees, employers may also violate the Insurance Code 1871.4 by committing workers' compensation fraud.  If an employer makes a fraudulent or false statement concerning workers' compensation, the employer may face fraud charges. An employer may make a false representation by lying to the insurer regarding the number/count of employees. It is also a form of fraud for the employer to misrepresent a worker's job duties. It is also an offense for an employer to lie to a worker regarding the scope of the benefits or to try to discourage an employee from filing a claim. 

A company may lie to an employee in various ways. For instance, when an employee suffers injuries in the workplace, the employer may tell the employee that he/she is not a beneficiary of the worker's compensation policy. The employer may state that since an employee has been in employment for a few months, the employee is not eligible for compensation.  This statement is untrue because a worker qualifies for compensation by being the company's employee. He/she does not qualify based on how long the person has been working for the company. If an employer makes such a statement and discourages a worker from seeking compensation, the employer may face fraud charges.

Workers Compensation Fraud Concerning California Health Care Fraud

The California PC 550 outlines several types of workers' compensation fraud, which intertwine with health care fraud.  You might violate the PC 550 if you intentionally make or cause the making of a fraudulent or a false claim. The claim should lead to the payment of healthcare compensation offered by workers' compensation insurance.  If you have not used a health benefit, but you proceed to make an insurance claim for the health benefit covered under workers' compensation insurance, you will face fraud charges.  If you seek several compensations for the same worker's compensation medical care benefit, you will be guilty of fraud. 

Employees and applicants commit workers' compensation fraud under PC 550.  However, it is also common for doctors and medical practitioners to violate California PC 550. The healthcare providers may collaborate with workers to defraud the insurers.  For instance, healthcare providers may claim to have provided healthcare services, yet the employee did not receive the said services. 

If a health practitioner commits workers' compensation fraud under PC 550, he/she may lose his/her medical license.  In addition to losing the medical practice license, the doctor may also face standard/regular criminal penalties. 

Violation of California Penal Code 549 PC

An employee or an owner of a business establishment may be guilty of workers' compensation fraud by referring, soliciting, or accepting business from certain entities or persons. To face fraud charges, you must have known that the entity or the person intended to commit workers' compensation fraud.   The main defendants in workers' compensation fraud, according to PC 549, include doctors and other healthcare providers like chiropractors.  A healthcare provider may face charges under PC549 if he/she engages in commercial bribery. It is also illegal for health practitioners to engage in kickbacks aimed at taking advantage of defrauding the workers' compensation system. 

Consequences for Workers Compensation Fraud

The consequences you face for a worker's compensation fraud will depend on the exact form of fraud you commit.  For instance, an offense under the California Insurance Code 1871.4 may attract misdemeanor or felony charges and is, therefore, a wobbler.  When deciding whether to charge you with misdemeanor or felony, the prosecutor will consider your criminal history and the facts surrounding your case.  

If the prosecutor charges a violation under Insurance Code 1871.4, the consequences include a summary or misdemeanor probation. You might also serve jail time not exceeding one year in a California county jail. You might also have to pay hefty fines not exceeding $150,000 or twice the value/amount of the value of the fraud, whichever is higher. The court might also require you to pay restitution to the victim. This entails reimbursing the victim for the loss the victim may have suffered because of the fraud. 

If the prosecutor charges an offense under PC 549 as a felony, the consequences include serving a felony, also known as formal probation.  This probation has more requirements than summary probation. While on felony probation, you might have to meet with the probation officer regularly. You might also have to make regular visits to the probation office. 

For a felony conviction under Insurance Code 1871.4, you might have to serve time in county jail following the California realignment program. You might spend two years, three years, or five years in a county jail in California.  The court might order you to pay a fine not exceeding $150,000 or twice the value/amount of fraud, whichever is higher. You might also have to pay restitution to people who suffer losses during the fraud.  

Consequences from Violation under PC 550

For a violation under PC 550, the prosecutor may assign misdemeanor or felony charges.  For misdemeanor offense under PC 550, the penalties include serving misdemeanor probation in California. You might also be subject to jail time of up to one year in a county jail in California. Other consequences for misdemeanor offense include paying fines of up to $10,000.

If you commit felony workers compensation fraud under California PC 550, the consequences include serving felony or formal probation. You might also serve two, three, or five years in county jail, according to the California realignment program. The applicable fines for felony violations under PC 550 may be up to $50,000.  The penalties may also be double the amount of fraud, whichever is higher. 

In some instances, a worker's compensation fraud under PC 550 is always a misdemeanor. The fraud may attract misdemeanor charges if the overall/total value of the fraud does not exceed $950.  In considering the value of workers' compensation fraud, the court might consider your multiple fraud crimes for the past 12 consecutive months. 

If the prosecutor charges an offense under PC 550 as a misdemeanor, the penalties will include a jail time not exceeding six months in a California county jail.  You might also have to pay a fine that does not exceed $1,000.

Consequences for a Workers Compensation Fraud under PC 549

A crime under the California PC 549 is a wobbler under California law for a first offense. However, if you commit a second or subsequent offense, you automatically face felony charges.  For a misdemeanor offense under PC 549, the consequences include serving jail time not exceeding one year in a county jail in California.  The court might also order you to pay a fine not exceeding $50,000 or twice the value/amount of fraud involved, whichever is higher. 

For a felony offense, you might serve jail time of sixteen months, two years, or three years in county prison. You might also pay a fine not exceeding $50,000 or double the value of the fraud, whichever is higher. 

Facing Civil Penalties for Workers Compensation Fraud in California

In addition to criminal charges for workers' compensation fraud, California law also has hefty civil fines for various types of workers' compensation fraud.  You might face civil penalties if you intentionally misrepresent a fact to get workers' compensation fraud at a lower than the statutory rate. This type of workers' compensation fraud is common among employers.  You might face civil workers' compensation fraud charges if you present or you cause the presenting of fraudulent or false statements supporting or opposing a claim for workers' compensation. You should make a false statement to get or deny the worker's compensation benefits. 

You might face civil charges for workers compensation fraud if you intentionally and knowingly participate in a 'for profit' service that advises patients to get medical-legal or medical services covered under workers' compensation insurance.  If you conspire or assist another person to do the mentioned activities, you might face civil workers' compensation fraud charges. 

Some of the common consequences for civil charges of workers compensation fraud include a civil consequence/penalty of not less than $4,000 and not exceeding $10,000 for every unlawful claim for workers' compensation you make. Consequences may also include an assessment not exceeding three times the amount of the medical or medical-legal expenses incurred by the workers' compensation insurance company due to your fraudulent acts.  If you commit an offense and you have a previous conviction under Insurance Law 1871.4 or the California PC 549, you might face additional civil penalties. The other civil penalty may be up to $4,000 for every service or item you obtain fraudulently. 

Professional Discipline Associated with Workers Compensation Fraud

A conviction for workers' compensation fraud under California law may trigger professional discipline. For instance, if a California doctor has a criminal conviction for an offense, which is substantially related to the functions, qualifications, or duties of the doctor, he/she may face professional discipline.  A medical practitioner may face professional discipline if he/she bills for services not rendered. 

Professional discipline does not only apply to doctors. Other medical professionals, like nurses and pharmacists, may be subject to professional discipline. For instance, nurses may be subject to nurse discipline. In some cases, a conviction for workers' compensation fraud may lead to the revocation of a nursing license.  A worker's compensation fraud charge may also harm the professional license of a pharmacist. 

Fighting Workers Compensation Fraud Charges in California

One of the most common and rapidly growing forms of insurance fraud in the U.S is the workers' compensation fraud. For this reason, many insurance companies, district attorneys' offices, and the California Department of Insurance have joined forces in fighting this crime.  Due to the significant commitment to fighting workers' compensation fraud, innocent people end up facing false accusations of workers' insurance fraud.

You do not have to give up if you are facing a conviction for workers' compensation fraud because, with the assistance of a competent attorney, you can fight the charges in court. Some of the common legal defenses you can adopt include:

1. Lack of Knowledge or Intent to Defraud

You cannot face charges for workers' compensation fraud unless it is evident that you knew that a particular presentation or statement was false. When making a false representation or statement, you must have had fraudulent intent. An insurance investigator may term a genuine mistake or error as potential fraud and report you to the law enforcement officers. However, the prosecutor has to prove beyond doubt that you were aware that you were committing fraud. An experienced attorney can question the evidence of the prosecutor and negotiate for a reduction of your charges.

2. Lack of Enough Evidence

You might successfully fight workers' compensation fraud charges if the prosecutor does not have enough evidence against you. At times, conflicting medical diagnoses and doctors' reports may appear as a fraud, yet you are innocent. Prosecutors may take advantage of the complexity of workers' compensation fraud to accuse you of wrong. You can challenge this accusation with the assistance of an attorney.

Contact a Los Angeles Criminal Defense Attorney Near Me

If you are facing workers' compensation fraud charges in Los Angeles, the consequences can be detrimental. It is imperative to have an attorney by your side. An attorney can guide you through the legal process and help you come up with a good defense. The LA Criminal Defense Law Firm can assist you in fighting workers' compensation fraud charges. Contact us at 310-935-1675 and speak to one of our attorneys.