How to Report a Fraud Workers’ Compensation Claim

If you suspect someone has inappropriately filed a claim for workers’ compensation benefits, you must report a fraud workers’ compensation claim. The steps to do so include:

• Collecting any evidence you have of the fraudulent claim
• Filing the proper form with the California Department of Insurance (CDI) (if you are a citizen or an insurer)
• Talking with your insurance provider’s claims adjuster (if you are an employer)
• Waiting for a response from the CDI and providing them with any additional information they request

What Is Workers’ Compensation Fraud?

To understand what a fraudulent claim looks like, it is first important to define workers’ compensation.Most employers in California must carry workers’ compensation insurance. This insurance is available to any employee—part-time or full-time—who meets the following criteria:

• They suffered an injury or contracted an illness due to a hazard they encountered while performing the job for which they were hired.
• They promptly reported their injury through the proper channels.
• They have experienced negative consequences as a result of the injury, such as physical pain or missed workdays.

Employees who meet these qualifications are entitled to file a workers’ compensation claim, and their employer’s insurer must respond to the claim within 90 days.Employees with legitimate claims are eligible for benefits that cover their medical bills, disability, lost wages, and even retraining expenses as necessary.

Reporting Workers’ Compensation Fraud

How can you tell if a workers’ compensation claim is fraudulent? Fraud is not always obvious, but you can look for the following signs:

• The employee is vague or contradictory about how, when, or where their injury occurred.
• The employee’s injuries seem to change drastically over time. (Note that some amount of change may be legitimate if, for instance, a doctor discovers injuries the employee was not aware of when they first reported.)
• There is no evidence from witnesses, surveillance footage, or the state of the workplace to corroborate the employee’s story. Alternatively, if evidence directly contradicts the employee’s story, this could also be a sign of fraud.
• The employee has tried to file fraudulent claims in the past.
• The employee’s name does not appear on your list of employees.

If you suspect fraud in a workers’ compensation claim, alert the CDI immediately. The Department has different reporting forms for insurers versus ordinary citizens, so make sure you select the right form. An employer who suspects fraud can go directly to their insurance provider with their concerns, and the insurer can then contact the CDI if appropriate.

If you are unsure if fraud has occurred or have any questions about how to report fraud, you can always consult a workers’ compensation attorney. They could tell you if any part of the employee’s claim seems suspicious.

Providing Proof of Workers’ Compensation Fraud

You do not have to be one hundred percent certain that fraud has occurred to make a report: the authority you report to has the responsibility of finding concrete evidence.That said, when you report the suspected fraud, you will be expected to support your claim with enough facts or materials to justify your concerns. Such materials could include things like:

• Your personal observations or recollections of contradictory behavior (e.g., if the employee mentioned being injured outside of work just before they tried to file a claim based on that injury)
• Statements from other employees that contradict what the employee said in their claim
• Texts or emails from the employee that contradict what they said in their claim
• Employment records that show the employee was not or should not have been performing the task that caused their injury
• Photos or video footage showing the accident did not occur as the employee stated or that show the employee behaving in a manner inconsistent with their claimed injury (e.g., walking easily after claiming to break their leg)

The more information you can provide, the more solid your case may be, and the more likely the CDI can respond swiftly and decisively.

What Happens After You Report Fraud?

After filing your report, the CDI or the insurance company will consider what you have submitted. They may contact you to ask additional questions, such as if you have any ideas about where they can find more information.

If the CDI’s investigation finds proof of fraud, the employee’s benefits will be terminated. They may also face disciplinary actions, such as being compelled to pay back any benefits they have already received.

If the CDI finds no proof of fraud, the case will be closed, and the employee will continue to receive benefits. You will not be prosecuted or sued for filing your report: as the CDI says, “filing a good faith report” is not a crime.

Other Forms of Workers’ Compensation Fraud

You should be aware that employees are not the only ones who can commit workers’ compensation fraud. Other parties who can commit fraud include:

• The employer, if they claim to have an insurance policy but do not or misrepresent the type of work their employees do
• The insurer, if they deny a claim despite knowing it is legitimate
• A healthcare provider, if they try to charge the insurer for services they did not provide
• A medical examiner, if they deliberately misdiagnose the employee’s condition

The process of reporting these types of fraud is different from how to report a fraud workers’ compensation claim.

If you suspect someone is trying to cheat you out of the benefits you deserve, consider hiring a workers’ compensation attorney to represent you. They can investigate the alleged fraud and take all necessary steps to protect you.

Get Help With Your Workers’ Comp Claim

The workers’ compensation attorneys at KJT Law Group understand how the workers’ comp system works and how to protect the system from fraudulent claims. For more advice on how to report a fraud workers’ compensation claim or file a legitimate claim of your own, Contact call our office at (818) 507-8525. We give free case reviews.