Worker’s Compensation Investigation

The workers’ compensation insurance in California, is a no-fault system.  An employee filing a worker’s compensation claim is not required to prove that the injury was another person’s fault in order to receive workers’ compensation benefits in the state of California.  All the employee is required to prove is that he or she was working on the job at the time of the incident and they were injured. The worker’s compensation relaxed legal system in California welcomes and entices scammers, con-artist and anyone to commit insurance fraud through filing a worker’s insurance claim.  Of course medical bills and lost wages are covered by Worker’s compensation insurance or YOU.  If you don’t worker’s compensation insurance; I urge you to hire a private investigator and start a workers’ compensation investigation soon as possible.  If the state of California Workers’ Compensation Insurance fund covers the claim and pays out than they will subrogate through you, your company or assets.  In other words you will be liable to pay back all the money to the State of California Workers’ Compensation Insurance fund. You will not be able to file for bankruptcy, there is now way out.

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  1. A thorough background check investigation in order to uncover and explore any previous worker’s compensation claims or other fraudulent claims.
  2. The background check investigation reveals all past address, employment and associates history.
  3. Surveillance the claimant and video tape all activities; including driving habits.
  4. Capture a video of the claimant while working, carrying items, exercising, jumping, running, swimming or any activity that contradicts the injury claim.
  5. Store and seal the evidence according to court procedures.

Our licensed private investigator are trained, experienced and understand the requirements in order to prove Worker’s compensation fraud.  Combined Experience of over 30 years investigating fraudulent claims.  

Workers' Compensation investigation

Workers’ Compensation investigation

Worker’s compensation investigations during 2012 to 2013, have led to a total of 815 arrests.  The district attorneys has prosecuted 1,329 cases with 1,545 suspects, resulting in 721 convictions for worker’s compensation fraud. 

In summary here are the statistics for Worker’s compensation fraud investigations During 2012 to 2013:

  •  Arrests made in connection with Worker’s Compensation fraud investigations: 815
  • The district attorney prosecuted cases with Worker’s Compensation fraud investigations  1,329 cases with 1,545 suspects
  • The district attorney prosecuted convicted cases for Worker’s Compensation fraud: 721
  • The district attorney prosecuted Restitution for Worker’s Compensation fraud investigations:
  • The amount of $24,862,189 was ordered in connection with these convictions and $4,890,396 was collected during Fiscal Year 2012-13.
  • The Total amount of worker’s compensation fraud that wasn’t collected through prosecution was $247,922,658.  Actually this is not an accurate estimate since many worker’s compensation cases were not investigated or addressed correctly.

Fraudulent workers’ compensation claims is an easy money: sit home, watch TV, enjoy life and relax, for criminals.  

Private investigators are up early to catch a worker’s compensation claim faker.

Workers Compensation fraud

Workers Compensation fraud

Good news; The Workers’ Compensation Fraud Program was established in 1991. The legislature made workers’ compensation fraud a felony, required insurers to report suspected fraud, and established a mechanism for funding enforcement and prosecution activities. The legislation established the Fraud Assessment Commission to determine the level of assessments to fund investigation and prosecution of workers’ compensation insurance fraud.

Workers’ compensation insurance fraud occurs in simple and complex schemes that often require difficult and lengthy investigations. Most of the time, employees exaggerate or even fabricate injuries. Unfortunately, Insurance companies “pick up the tab,” passing the cost onto policyholders, taxpayers and the general public.  

Regrettably, we all pay out of pockets every day for the Worker’s compensation program through California employers who are legally required to be insured or self-insured. Workers’ Compensation Fraud has caused approximately an aggregate assessment for Fiscal Year 2012-13 of $53,445,000.

During Fiscal Year 2012-13, the Fraud Division identified and reported 5,151 suspected fraud cases; (SFCs) assigned 847 new cases, made 268 arrests and referred 309 cases to prosecuting authorities. Potential loss amounted to $212,710,721.
Workers’ Compensation Fraud Convictions information was found through the District Attorneys’ Workers’ Compensation Program.

Fraud Claims and Forms
Suspected Fraudulent Claims (SFCs)
The Fraud Division has established a method for insurers to report suspected insurance fraud. It is important to know that notification of insurance fraud may be made anonymously. You may contact any of the Fraud Division Regional Offices directly responsible for your county. Other types of complaints may be directed to the Department’s Consumer Services Division. For further information about the Fraud Division and its programs, visit the Fraud Division’s home page.
The Insurance Code states that no insurer, or the employees or agents of any insurer, shall be subject to civil liability for libel, slander or any other relevant cause of action by virtue of providing information concerning a Suspected Fraudulent Claim (SFC) to law enforcement, including the California Department of Insurance, Fraud Division.

There have been some minor upgrades to our intake process that will allow us to email the initial status letters to a referring Special Investigative Unit (SIU). The Fraud Division receives on average 27,000 referrals each year across all fraud programs. Until recently, the process required the Fraud Division to print and mail the initial status letters to the referring SIU. The letter will now be sent to the email address that is provided on the FD-1 or eFD1. If no email address is provided, the letter will be mailed.

Suspected Fraudulent Claim Form (electronic eFD-1)
Registration to Submit Electronic eFD-1s on a Continual Basis (i.e. Insurers, TPAs, Self-Insureds)
Suspected Fraudulent Claim Form (electronic eFD-1)

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