Workers’ compensation is meant to be a lifeline—offering medical and financial support to employees injured on the job. But if you’re accused of workers’ compensation fraud, that safety net can quickly turn into a legal trap. In California, even minor errors or miscommunications can lead to serious criminal charges, sometimes even felony prosecution.
At Simmons Wagner, LLP, we’ve seen firsthand how honest workers can get caught up in fraud investigations. This blog explores how these accusations arise, what actions might lead to criminal charges, and how you can protect yourself if you’re under scrutiny.
What Is Workers’ Comp Fraud?
Workers’ comp fraud involves intentionally deceiving the system for personal gain. This includes both employees and anyone who knowingly contributes to a fraudulent claim—such as healthcare providers, attorneys, or others in the process.
Common Actions That May Be Considered Fraud:
- Filing multiple claims for the same injury
- Exaggerating symptoms or claiming new injuries that never happened
- Working another job while collecting benefits
- Using medical services and billing them as work-related when they’re not
- Encouraging someone to lie to obtain benefits
- Providing false information to delay or deny a valid claim
Importantly, intent is key. A genuine mistake in paperwork or a misunderstanding about eligibility is not the same as deliberate fraud—but investigators often treat both with equal seriousness at first.
How Fraud Investigations Begin
Fraud allegations typically start when:
- An employer or insurance carrier notices inconsistencies in a claim
- A private investigator captures video evidence that contradicts a worker’s claim (e.g., lifting heavy objects while claiming a back injury)
- A healthcare provider reports irregularities in treatment or billing
- Someone anonymously reports suspicion of fraud
Once flagged, these claims are referred to the California Department of Insurance (CDI) or local district attorneys for review. If criminal charges are filed, you may be facing felony prosecution, restitution, fines, and even jail time.
Legal Penalties for Workers’ Comp Fraud in California
Workers’ compensation fraud is often charged under California Insurance Code §1871.4, a felony punishable by:
- Up to 5 years in state prison
- Fines up to $150,000 or double the fraud amount (whichever is greater)
- Restitution to the insurance company or employer
- A permanent criminal record affecting future employment
Even if no benefits were paid out yet, an attempt to commit fraud can be enough for a conviction.
What If You Didn’t Mean to Commit Fraud?
Not all cases of suspected fraud are malicious. In fact, many arise from:
- Confusing paperwork or incorrect claim forms
- Misunderstanding doctor instructions
- Doing limited work or side jobs without knowing it could impact your claim
- Delayed reporting of symptoms, leading to questions about legitimacy
At Simmons Wagner, LLP, we explore every angle of your case to show:
- You did not act with fraudulent intent
- You were misinformed by your employer or claims adjuster
- Your actions were within your legal rights under California law
- The evidence has been misinterpreted or taken out of context
Building a Strong Defense with Experienced Legal Help
Being accused of workers’ compensation fraud can feel isolating, especially when your reputation and livelihood are on the line. The key to protecting your rights is to act quickly and work with an attorney who understands both criminal law and California’s workers’ comp system.
At Simmons Wagner, LLP, we’re committed to defending workers facing unfair or exaggerated fraud allegations. We work to uncover the facts, protect your legal rights, and push back against assumptions that could cost you everything.
Facing Fraud Charges? Let Us Help You Fight Back
Don’t let a fraud investigation ruin your future. If you’re being investigated—or have already been charged—with workers’ comp fraud in California, reach out to Simmons Wagner, LLP today at (949) 439-5857 for a confidential consultation. We’ll help you navigate the process, build a strong defense, and fight for the fair outcome you deserve.