Cal. Code Regs. tit. 10 § 2698.51

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 2698.51 - Definitions

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 1872.8et 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.

Cal. Code Regs. Tit. 10, § 2698.51

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.