Workers’ compensation is a benefits program to help employees who sustain work-related injuries. The compensation helps them seek medical treatment and cater to their other needs before they can resume work. This benefits program is for all eligible employees, regardless of their negligence or fault in the workplace injury. In exchange, injured employees lose their right to file a civil suit against their employers in case of a workplace injury. The system benefits employees and employers as well. However, that does not always happen because some employers and employees commit workers’ compensation fraud.

Fraud occurs when an employer or employee falsifies information to recover benefits for which they are not entitled. It is a grave offense that can result in a lengthy jail sentence and a hefty court fine. A conviction comes with additional consequences, too, including a damaging criminal record and ineligibility for other benefits. If you face workers’ compensation fraud charges in Monterey, we can help. Our skilled attorneys at Monterey Criminal Attorney can protect your rights and mount a solid defense against your charges for a fair outcome.

An Overview of Workers’ Compensation Fraud

Work-related injuries are prevalent in California. When they happen, employees and employers suffer gravely. Workers’ compensation is an insurance program that benefits employers and employees in case of a workplace injury. The program offers monetary benefits to injured employees to enable them to seek medical care and cater to their other needs before they can engage in gainful employment again. It also protects employers from endless lawsuits in case of a workplace accident. Injured employees can recover total compensation for their immediate needs after an injury in exchange for pursuing compensation through lawsuits against their employers.

Sadly, some people take advantage of systems like these to receive compensation to which they are not entitled. It makes it impossible for the program to serve eligible applicants as it should. That is why workers’ compensation fraud is treated with much seriousness. If you are found guilty of defrauding or attempting to defraud the workers’ compensation program, you could be sentenced to many years and required to pay a hefty court fine.

You can commit workers’ compensation fraud in many ways. For example, you can submit false information in your application or file an incomplete benefit application. An employer can also provide false statements in their claim to deny deserving employee benefits after a workplace injury. Some healthcare professionals also commit fraud when they provide falsified medical reports to solicit benefits for a nonexistent illness or injury. California law has various statutes that address this kind of fraud.

Insurance Act 1871.4

This is the leading law against workers’ compensation fraud in California. According to this statute, you commit fraud when you knowingly do one or more of the following:

  • Make a fraudulent or false material statement, or cause another person to make a fraudulent or false statement to obtain or deny workers' compensation benefits
  • Present or cause another person to represent a fraudulent or false oral or written material to support or oppose a claim for compensation benefits
  • Aid and abet or conspire with another person to commit workers’ compensation fraud
  • Make or cause another person to make a fraudulent or false statement regarding their eligibility for benefits to stop an eligible claimant from claiming or pursuing workers' compensation benefits.

Remember that workers' compensation is insurance coverage employers must take and pay for their employees. It helps injured employees receive compensation for medical care, temporary disability before they can resume full-time employment, and permanent disability if they cannot engage in gainful employment after an injury. The coverage also offers death benefits for employees who lose their lives in a work-related accident.

An injured worker can obtain these benefits even if the workplace accident in which they were injured is their fault. The insurance company does not consider fault when granting these benefits. But in exchange for that, the worker loses their right to sue their employer in civil court after a workplace accident.

Making a Statement

While there are many ways through which you can commit workers’ compensation fraud, making a fraudulent or false statement is the most common of them all. A statement can be any of the following:

  • A written or oral statement from a claimant
  • A notice
  • Bills for services received
  • Proof of illness or injury
  • Payments for particular services
  • Doctor and hospital records
  • Tests and x-ray results
  • Proof of legal or medical expenses
  • Any other tangible evidence of your injury, payment, or loss

You commit insurance fraud under this statute when you make a material statement that causes you to receive or deny workers’ compensation benefits fraudulently. Material statements are representations of the details or facts of the matter. Thus, they are directly significant and relevant to the evaluation and investigation of the insurance petition.

For example, if you are in a workplace accident that aggravates an existing injury, you must disclose that injury to the insurance company when claiming workers’ compensation benefits. Sadly, some employees hide that they have an existing injury and claim total compensation from the insurance provider. Remember that the insurance provider relies on your information to decide your case and the compensation you deserve. Failing to declare relevant information or conspiring with your physician to hide crucial information from the insurance provider can result in fraud-related charges.

Knowingly Making False Statements

The prosecutor will file workers’ compensation fraud charges if they can verify that you knowingly or deliberately made false statements to receive or deny benefits. A false statement can be written or verbal. You must have made it to the insurance provider, knowing it is untrue and intending to obtain benefits you do not deserve. An employer can face charges for making false statements if they do so with the intent to deny a deserving worker insurance benefits. Here are other ways you can knowingly make false statements to an insurance provider:

  • Failure to disclose an existing injury
  • Lying about the gravity of the injury
  • Working on another job for extra pay while still claiming workers’ compensation benefits
  • Faking an injury or illness or staging an accident to receive benefits
  • Claiming that your injury is work-related while, in the actual sense, you were injured outside of work
  • Claiming benefits from another employer’s insurer, alleging that you were injured in their workplace
  • Failure to disclose that you have received workers' compensation benefits before
  • Lying to the insurance provider about how many workers are in your company
  • Lying to the insurance provider about the nature of work performed by the injured worker
  • Misrepresentation of facts to deter or discourage a deserving worker from pursuing compensation

In this case, your intent will be questioned, as the prosecutor must demonstrate that you acted with fraudulent intent to obtain a conviction. While providing intent is a significant challenge for prosecutors, all the prosecutors must prove that you knowingly made a false statement or representation. If your actions were not a genuine mistake or accidental, the court will deliver a guilty verdict. The prosecutor will also demonstrate that your actions affected or could have affected the insurance company’s decision on whether to approve the claim and the amount to award.

Penal Code 550

This penalty code penalizes all forms of benefit fraud in California. Since workers’ compensation also covers medical needs, PC 550 applies to healthcare fraud. According to this statute, you commit fraud when you knowingly do the following:

  • Make or cause another person to make a false claim to receive medical care benefits under workers’ compensation benefits
  • Claim medical compensation when you have received benefits from the same under the workers’ compensation coverage
  • Submit multiple compensation claims for one workplace injury to your employer’s insurance provider

Different parties commit workers' compensation fraud, violating this statute, including workers, their employers, and healthcare professionals.  For example, you can commit fraud as a medical professional or doctor when you present or conspire with another person to present a false claim. In this case, the consequences of a conviction will be more than prison time and a hefty fine. You can lose your professional license.

Penal Code 549

Workers compensation fraud occurs under PC 549 when a staff or proprietor knowingly accepts, solicits, or refers trade to an organization or company, disregarding that the organization or company can use that information to commit fraud. Different parties can face charges under this statute, including chiropractors, doctors, and other medical professionals. The consequences will be grave when you accept or solicit a bribe or kickback to benefit financially or to give an unfair benefit to another person against an insurance provider.

How Investigations for Workers Compensation Fraud Are Conducted

If you are suspected of committing workers’ compensation fraud, the police will investigate and arrest you, while the prosecutor will file charges against you in court. The insurance company will also conduct an independent investigation. Insurance companies are always on the lookout for fraudulent claims. Thus, they investigate every claim they receive carefully and only grant benefits once satisfied with a claim. This is necessary to avoid losing thousands of dollars to fraudsters. Therefore, if an insurance company suspects a fraudulent claim, they can contact the police for further investigations and arrests.

Here are some of the red flags insurance providers look out for when investigating workers’ compensation claims:

  • Varying or suspicious reports about the injury or accident
  • Inability by the claimant to provide a detailed report about the workplace injury or accident
  • The injury for which a worker claims compensation is not connected to their job or duties
  • A claim that follows a dismissal, demotion, or disagreement with an employer
  • A claim that comes right after the worker returns from leave or holiday
  • A claim from a worker who has benefitted from workers’ compensation insurance once or several times in the past
  • A claim that occurs in the course of a financial crisis or severe debt
  • When a claimant visits several doctors for different diagnoses for the same injury

If your claim is suspicious, the insurance company will thoroughly investigate it to ensure you qualify for workers’ compensation benefits. If it has suspicious clauses or statements, the insurance company will place it on hold until an investigation clears it. If the insurer confirms its suspicion, they can call the police for an arrest and further investigation. The insurance company can also file a civil suit against you for damages incurred through your fraudulent acts.

Possible Penalties for Workers’ Compensation Fraud

Workers compensation fraud is a grave offense resulting in a lengthy prison sentence and a hefty court fine. The exact penalties you receive largely depend on the statute under which the prosecutor files your case, and your criminal history.

A violation of Insurance Act 1871.4 is a wobbler offense. This means that the prosecutor can bring felony or misdemeanor charges against you. If the court finds you guilty of a misdemeanor, you will likely receive a six-month jail sentence, misdemeanor probation, and $150,000 in court fines or two times the fraud amount (the higher of the two is more likely). The judge can also order you to pay restitution to the victim of your crime. If the court finds you guilty of a felony, you will likely receive the penalties below:

  • Felony probation
  • Two, three, or four years in jail
  • Up to $150,000 in court fines or twice the fraud amount
  • Victim restitution

A violation of PC 550 is a wobbler offense. You will likely receive these penalties for a misdemeanor conviction:

  • Misdemeanor probation
  • A twelve-month jail time
  • Up to $10,000 in court fines

If the judge convicts you of a felony under PC 550, you could receive these penalties:

  • Felony probation for three to five years
  • Two, three, or four years in jail
  • $50,000 in court fines or twice the fraud amount (whichever is more).

However, there is an exception under this law. The prosecutor will file misdemeanor charges if the fraud amount does not exceed $950 within a year. This means more lenient penalties for you.

PC 549 is also a wobbler offense for first-time offenders and a felony for subsequent offenders. A misdemeanor is punishable by a year in jail and $50,000 in court fines. The judge can sentence you to probation instead of jail. A conviction for a felony is punishable by up to three years in jail.

Other Consequences of a Conviction for Workers’ Compensation Fraud

A fraud-related conviction is generally life-altering. You must deal with a damaging criminal record even after serving your jail sentence and paying all court fines and victim restitution. Anyone conducting a background check on you will know about the conviction and can treat you accordingly. For example, a potential employer can deny employment because of your criminal background. A landlord can refuse to rent or lease to you for the same reason.

A conviction for workers’ compensation fraud can also affect your professional license. For example, if you are a medical professional, you could lose your license to revocation or suspension, based on the details of your case, making it difficult for you to practice and earn a living until your licensing board reinstates it or issues you a fresh license.

A felony conviction for workers’ compensation fraud will also affect your gun rights. Remember that felons are prohibited from purchasing, possessing, or using firearms in California. The judge can revoke or suspend your gun rights for a few years or more, depending on the circumstances of your case.

Fighting Your Wokers’ Compensation Fraud Charges

A conviction for workers’ compensation fraud is devastating, resulting in severe consequences, including imprisonment, a hefty court fine, and a life-changing criminal record. Fortunately, you can fight your charges with the assistance of a skilled criminal attorney. Your criminal attorney can use one or more of the legal defense strategies allowed to obtain a favorable outcome for your case. Here are some of the best strategies that could help your situation:

You Did not Act With a Fraudulent Intent

All fraud-related cases require the prosecutor to demonstrate that you acted with fraudulent intent. A fraudulent intent occurs when you do or fail to do something for an unlawful gain or to cause another person to lose something valuable (like money). Suppose you omitted crucial information in your claim or submitted false information but did not have fraudulent intent. In that case, you can use this defense to compel the judge to dismiss your charges.

An experienced criminal attorney can help you mount a solid defense to weaken the prosecutor’s case against you. If the prosecutor cannot prove beyond a reasonable doubt that you acted with fraudulent intent, the judge will dismiss the case,

The Prosecutor Lacks Sufficient Evidence to Obtain a Guilty Verdict

The police must gather and table crucial evidence demonstrating your fraudulent acts during the trial. The prosecutor relies on this evidence to prove your case beyond a reasonable doubt. Remember that the prosecutor bears the burden of proof in criminal cases like this. The court will dismiss your case if they do not have enough evidence.

An aggressive criminal attorney will fight the prosecutor’s evidence to weaken the case. For example, your attorney can say that you provided varying information after your accident because you were confused or could not recall the facts correctly. This will compel the judge to dismiss your charges.

The Employee is on a Contract

An employer facing workers’ compensation fraud charges for providing contradicting information about a particular employee can use this strategy. Remember that the workers’ compensation scheme only benefits permanent employees. If an employee is on contract, they do not have the right to claim compensation after a workplace injury. You can provide a copy of the employee’s contract as proof of this to compel the judge to dismiss your charges.

The Police Violated Your Rights

If you believe your rights were violated at any stage of the legal process, you can use that to your advantage. If the police misconduct themselves in any way, the judge can dismiss any evidence gathered through the misconduct. That could leave the prosecutor with insufficient evidence to obtain a guilty verdict.

The police can violate your rights in many ways. For example, if the officer used force, violence, or tricks to obtain information from you, the evidence gathered is inadmissible in court. The arresting officer should also have read your Miranda rights and granted you your right to counsel before questioning you. If that did not happen, the judge would dismiss any evidence the officer had gathered from you.

Workers Compensation Fraud and Related Charges

The law has some statutes closely related to workers’ compensation fraud. The most closely related ones include the following:

Grand Theft

According to PC 487, grand theft happens when you take another person’s property without permission, and the property’s value exceeds $950. Most fraud-related offenses overlap with theft crimes because they involve financial loss to the victim. If your workers’ compensation fraud case satisfies the legal meaning of grand theft (specifically theft through false pretenses), the prosecutor will also charge you with grand theft.

Grand theft is also a wobbler offense. A misdemeanor is punishable by one year in jail, while a felony is punishable by up to three years.

PC 470, Forgery

You commit forgery in many ways, including signing another person’s name, faking another person’s handwriting or seal, or forging a legal document. If the facts of your case include any of the acts prohibited under PC 470, the prosecutor will also file forgery charges against you. Forgery is also a wobbler offense, punishable by up to three years in jail.

Find an Experienced Criminal Attorney Near Me

Do you or your loved one face workers’ compensation fraud charges in Monterey?

Fraud charges are grave, resulting in severe consequences, including a lengthy jail term and a hefty court fine. But you can fight for a favorable outcome with the help of an experienced criminal attorney.

We offer legal representation, protect your rights, and fight alongside you until you are happy with the outcome of your case at Monterey Criminal Attorney. We will also help you navigate the complex legal process and discuss your options for informed decision-making. Our aggressive attorneys will only stop once you are satisfied with the results. Call us at 831-574-1791 to better understand your charges, options, and our services.