Dept. of Insurance SIU Guidelines and Protocols

The California Department of Insurance Criminal Investigations Branch, in conjunction with the Workers’ Compensation Fraud Advisory Committee, has developed the first six modules of a new manual, Special Investigative Unit Guidelines & Protocols, to assist workers’ compensation insurers and employers in their antifraud efforts. The manual provides general guidelines to industry personnel involved in the anti-fraud effort. Additional modules should be released later this year.

While use of this information is strictly voluntary, in California, an insurer’s obligation to combat fraud is mandated by statute and regulation. Insurance Code §1875.20 requires insurers to maintain Special Investigations Units (SIUs) to flag and investigate potentially fraudulent claims, and Insurance Code §1875.21 mandates that insurers employ in-house SIU staff or contract with a third party for SIU services. California Code of Regulations (§2698.40 et seq.) also requires insurers to provide anti-fraud training to claims examiners and SIU staff, and specifies necessary elements of anti-fraud plans and investigations.

The Department of Insurance audits insurers to assure that they fully comply with statutory and regulatory anti-fraud provisions. Violations can lead to fines and/or a 1-year suspension of the insurer’s certificate of authority, so the Institute strongly recommends that appropriate personnel at your company obtain, review and keep this information. CWCI members may obtain a free copy of the manual by calling the Institute at 510-251-9470, or by sending a written request to:

California Department of Insurance
Criminal Investigations Branch, Fraud Division
Attn.: Mary Spaid
9342 Tech Center Drive, Suite 100
Sacramento, CA 95826

CDI has not copyrighted the material, so companies are free to make additional copies for staff training and reference.

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