California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 3 - Program for Investigation and Prosecution of Workers' Compensation Insurance Fraud › Section 2698.51 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For the purposes of these regulations:
(a) "Application" means the written document
				  submitted to the Commissioner by which a local district attorney requests
				  program funding, including a plan setting forth the district attorney's
				  intended use of funds to enhance investigation and prosecution of workers'
				  compensation insurance fraud.
(b)
				  "Assessment" means the surcharge collected from insurers and self-insured
				  employers to support the program to enhance investigation and prosecution of
				  workers' compensation fraud.
(c)
				  "Case" means the file set up by the California Department of Insurance Fraud
				  Division (formerly, the Bureau of Fraudulent Claims) and/or the California
				  Department of Insurance Investigations Bureau, and/or district attorney in the
				  course of and for the purpose of investigation, development of evidence and
				  prosecution of individual or consolidated activities of suspected workers'
				  compensation fraud.
(d) "Claim"
				  means the request for payment of workers' compensation benefits which has been
				  submitted to an insurer as defined in Section
				  1877.1(c)
				  of the Insurance Code.
(e)
				  "Commissioner" means the Insurance Commissioner of the state of
				  California.
(f) "County Plan" means
				  the plan submitted to the Commissioner as part of the application process by
				  the local district attorney which details the projected use of the funds sought
				  pursuant to these regulations.
(g)
				  "Department" means the California Department of Insurance.
(h) "District Attorney" means the prosecuting
				  officer of a California county jurisdictional district.
(i) "Division" means the California
				  Department of Insurance Fraud Division, formerly known as the Bureau of
				  Fraudulent Claims. The former Bureau was designated a Division subsequent to
				  the implementation of CIC sections
				  1872.8
et seq
.
				  The California Department of Insurance Investigations Bureau is responsible for
				  investigating premium fraud.
(j)
				  "Incidental Expenses" means those costs incurred by the California Department
				  of Insurance and the California Department of Industrial Relations to
				  administer the program and may include Fraud Assessment Commission expenses,
				  costs of collection of assessments, administrative support of the Fraud
				  Division program component, management of the distribution and oversight of
				  monies allocated to the district attorneys.
(k) "Local Program Funding" means that
				  portion of the funds collected and distributed to district attorneys pursuant
				  to section
				  1872.83 of
				  the Insurance Code.
(l) "Premium
				  Fraud", also commonly called "employer fraud", are those acts of fraud,
				  including and not limited to under-reporting payroll, misclassification of
				  employees' duties, experience modification evasion, committed by or at the
				  direction of an employer, for the purpose and with the effect of reducing
				  premium liability.
(m) "Program"
				  means those activities conducted by the Department, the Department of
				  Industrial Relations, and any other agency which are necessary to fund or
				  administer enhanced investigation and prosecution of workers' compensation
				  insurance fraud through assessments on insurers as defined in Section
				  1877.1(c)
				  of the Insurance Code and the distribution of funds to the Fraud Division to
				  district attorneys for the purpose of investigation and prosecution of workers'
				  compensation insurance fraud.
(n)
				  "Regulations" means these regulations, California Code of Regulations, Title
				  10, Chapter 5, Subchapter 9, Article 3.
(o) "Suspected Fraudulent Claim" means a
				  claim referred to the Fraud Division because the insurer, employer or claims
				  administrator suspects, knows or reasonably believes that the claim involves a
				  person who has committed a fraudulent act related to workers' compensation
				  insurance.
1. New
					 section filed 10-8-93; operative 11-8-93 (Register 93, No. 41).
2.
					 Change without regulatory effect amending subsection (n) filed 11-9-93 pursuant
					 to title 1, section
					 100, California Code of
					 Regulations (Register 93, No. 46).
Note: Authority cited: Section
						1872.83,
						Insurance Code; CalFarm Insurance Company, et al. v. Deukmejian, et al. (1989)
						48 Cal.3d 805, 824. Reference: Sections
						1872.83 and
						1872.9,
						Insurance Code.