Workers' Compensation Fraud

The law provides that in the absence of fraud, malice, or bad faith, no person providing information to the Fraud Unit will be subject to civil liability as a result of providing the information.

Employers that intentionally provide false information to obtain workers' comp. insurance at less than the proper rate may be subject to criminal prosecution. Examples include misrepresentation of an employee's rate classification, misrepresentation of payroll, failure to report injuries, and providing false information regarding ownership changes.

Claimants are required to report any earnings they receive while collecting workers' comp. benefits. The insurer or self-insured employer must send a Report of Earnings Form to the claimant at reasonable intervals, put at least twice per year, to complete and return. The Fraud Unit encourages insurers and self-insured employers to have a claimant sign a Report of Earnings Form prior to settling a claim. The Fraud Unit also suggests that the Report of Earnings form be sent with a benefit check. If this is not feasible, the adjuster may send the form separately by regular mail. If the Report of Earnings form is not returned, a second form should be sent by certified mail, return receipt requested. Failure to report earnings on the Report of Earnings form may result in the suspension of benefits and criminal prosecution.

Insurers and self-insured employers must notify the claimant of the effect of their endorsement of a benefit check by sending the claimant the Notice to Employees Regarding the Effect of Endorsement of Benefit Check form.

The law requires that the following language be printed on the back of the benefit check:

"I understand that endorsement hereon or deposit to my accounts constitutes my affirmation that I am receiving these workers' compensation benefits pursuant to law, that I have made no false claims or statements or concealed any material fact, in order to receive said benefits and that doing so would make me liable for civil and criminal penalties, including jail."

The law provides that when an employee endorses a workers' compensation benefit check, the employee is stating that he or she is qualified to receive benefits under the Workers' Compensation Act. Criminal sanctions may be imposed upon any claimant who endorses a benefit check to which they are not entitled.

The Fraud Unit advises that the following questions be asked and documented in all independent medical exam reports:

• Have you returned to work since your injury?
• Have you worked in ANY capacity since your injury?
• What type of physical activities do you engage in?
• What do you do on a daily basis?

The employee's responses to these questions provide further information for consideration in evaluating the claim and vital information to the Fraud Unit.