Workers’ Compensation in San Diego
Workers’ compensation is an insurance system designed to provide wage replacement and medical care costs to employees injured on the job. This service is provided in exchange for the employee waiving his/her rights to sue the employer for negligence. Workers' compensation is what is known as a “no-fault” system. This means that the injured employee does not have to prove that the injury was someone else's fault in order to receive benefits
Jurisdictions vary in terms of what and how these payments are made. California, for example, can include: medical care, temporary/permanent disability benefits, supplemental job replacement, psychological treatment, and death benefits. Typically, California pays workers compensation on a weekly amount.
The process, as you can see, involves many parties: employer, employee, claims agent, doctor, insurance provider, etc. And it can be a technical process with a lot of hoops to jump through, but the basic steps are:
1. Make sure your supervisor is notified of your injury as soon as possible. If your injury or illness developed gradually, report it as soon as you learn or believe it was caused by your job. If you don’t report your injury within 30 days, you could lose your right to receive workers’ compensation benefits.
2. File a claim. Your employer must give or mail you a claim form within one working day after learning about your injury or illness. If your employer doesn’t provide you with one, you can get it from the Division of Workers Compensation website.
3. Wait to hear back. If your claim is denied, it means the claims administrator believes your injury is not covered by workers’ compensation. If the claims administrator sends you a letter denying your claim, you have a right to challenge the decision. Don’t delay, because there are deadlines for filing the necessary papers!
California's main workers' compensation fraud statute is found under Insurance Code 1871.4. The legal definition of workers' compensation fraud under this law is doing any of the following:
- Making, or causing to be made, a knowingly false or fraudulent material statement or representation for the purpose of obtaining or denying any workers' comp benefits;
- Presenting, or causing to be presented, a knowingly false or fraudulent written or oral material statement in support of, or in opposition to, a claim for workers' comp benefits;
- Knowingly aiding/abetting or conspiring with anyone else to commit any act of workers' compensation fraud; or
- Making or causing to be made a knowingly false or fraudulent statement with regard to entitlement to benefits, with the intent to discourage an injured worker from claiming benefits or pursuing a claim.
Penalties for Workers Comp Fraud
Workers compensation fraud is a wobbler offense, meaning it can be charged as either a felony or misdemeanor. This is based on both the circumstances of the charges and the criminal history of the person charged.
Misdemeanor Workers Comp Fraud
When California workers' compensation is charged as a California misdemeanor, you may face:
- A maximum of one year in county jail;
- Informal probation;
- A fine of up to 150,000 or double the fraud amount, whichever is greater;
- Restitution to any parties who were victims of the fraud.
Felony Workers Comp Fraud
When California workers' compensation fraud is charged as a felony, you may face:
- A maximum of 2, 3, 5 years in county jail under CA realignment program;
- Formal probation;
- A fine of up to $150,000 or double the amount of the fraud, whichever is greater;
- Restitution to any parties who were the victims of the fraud.
Luckily, you have the option to contact a skilled criminal defense attorney who knows which, of the several, available defenses will be most beneficial to your case. The most common legal defenses are:
- Lacked Intent to Defraud
For example, many times a careless mistake on your part will be flagged as potential fraud by an insurance investigator—and reported to the authorities. The burden is on the prosecution to prove, beyond a reasonable doubt, that you knew you were submitting a false or fraudulent statement, and did not simply make a mistake.
- Insufficient Evidence
For example, many workers' comp insurance cases revolve around a complicated set of facts. Often these facts involve highly technical and sometimes conflicting medical diagnoses, doctor's reports, and other evidence that can be difficult for defendants and juries to make sense of. But prosecutors may not take advantage of this complexity and ambiguity to convict someone unjustly.
- False Accusation
For example, even if there are legitimate claims of workers comp insurance fraud, it doesn't necessarily mean that you are the guilty party. Perhaps someone in your office filed for a fraudulent claim and, when questioned, tried to escape his own liability by pointing the finger at you. Or perhaps you were the victim of identity theft and, as a result, you were also the victim of mistaken identity, since you are not the culprit who submitted the false claim.