Fraud and Violations
Compliance investigators refer businesses required to carry insurance coverage but who fail to do so to the WCA Enforcement Bureau for investigation. The Enforcement Bureau may seek fines against the non-compliant business, or seek to shut it down through a temporary restraining order.
The Enforcement Bureau investigates, and when necessary, prosecutes administrative and/or criminal violations of the Workers' Compensation Act and Rules.
Referrals to the Enforcement Bureau are made through a report form. The form is acknowledged, and at times the WCA sends a letter requesting additional information through a notice known as a Notice of Pending Investigation. The letter contains information on any allegations and seeks relevant information pertaining to the allegations. The letter specifies a date by which information is needed to avoid administrative penalties.
A prosecuting attorney evaluates referrals and determines if administrative or criminal charges may be warranted.
Reported violations include (but are not limited to):
- Bad faith
- Unfair claims processing
- Late/non-reporting of required claims data
Fraud occurs when a party intentionally misrepresents or omits relevant information that helps determine benefits. (§52-1-28.3)
Bad faith is intentional conduct that amounts to fraud, malice, oppression or willful, wanton or reckless disregard of the rights of any party.(§52-1-28.1)
Unfair claims processing is any practice that unreasonably delays or prolongs the payment of benefits at a rate inconsistent with the Workers' Compensation Act, whether intentional or not. (§52-1-28.1)
Retaliation occurs when an employer discharges, threatens to discharge or otherwise retaliates in terms or conditions of employment against a worker who files a claim for workers' compensation benefits. (§52-1-28.2)
Other technical violations include ( but are not limited to):
- Failure to display the workers' compensation poster
- Failure to report workplace injuries to the insurer within 72 hours (timely reporting)
- Failure to complete the proof of safety inspection
- Failure to comply with the Risk Reduction program
- Failure to make timely benefits payments
- Any party's failure to comply with mediation or adjudication rules
- Any health care provider's billing misconduct
Report a Violation of Workers' Compensation or Fraud
Use the WCA Fraud Prevention Poster to reinforce the message that any party committing workers’ compensation fraud will be prosecuted.