A Video Explaining Common Employee Fraud Allegations

An employee fabricates an injury altogether, or exaggerates a legitimate injury, in order to continue to receive benefits or more time off work.Show more

Multiple Claims/Identities:

An employee may make injury claims and receive payments from both their workers’ compensation carrier as well as a personal healthcare provider (double-dipping). Individuals may also file multiple claims with different employers, and may use different names or social security numbers to conceal their claims history.

Malingering
Common Employer Fraud Allegations
Common Service Provider Fraud Allegations
Common Employee fraud Allegations

The seminal decision interpreting California Insurance Code section 1871.5 is Tensfeldt v. Workers' Comp. Appeals Bd. (1998) 66 Cal.App.4th 116 (Tensfeldt). There, a city employee falsely claimed he injured his knee when he got out of a city truck; he actually injured his knee while playing basketball. (Id. at p. 119.) Tensfeldt was convicted of workers' compensation insurance fraud. While the criminal matter was pending, Tensfeldt filed a second workers' compensation claim, alleging the true circumstances of the knee injury, that was the subject of his false claim.

The Tensfeldt decision rejected the notion that Insurance Code section 1871.5 should be interpreted to completely bar workers convicted of workers' compensation insurance fraud (Ins. Code, § 1871.4) "from forever receiving or retaining any workers' compensation benefits connected with a claim for an otherwise legitimate industrial injury, without regard for the specific facts of the case." Nonetheless, the court held employee Tensfeldt was barred from receiving any benefits because he lied about the very fact of compensability.

© 2020 – Barry Zalma

Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves as an arbitrator or mediator for insurance related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims handling lawyer and more than 52 years in the insurance business. He is available at http://www.zalma.com and zalma@zalma.com.

Mr. Zalma is the first recipient of the first annual Claims Magazine/ACE Legend Award.

Over the last 53 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.

Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921

Read posts from Barry Zalma at https://parler.com/profile/Zalma/posts

Listen to the Podcast: Zalma on Insurance https://anchor.fm/dashboard/episodes Zalma on Insurance

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Go to the Insurance Claims Library –https://zalma.com/blog/insurance-claims-library/

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