On August 17, 2015, Evelyn Rivera went to see a doctor at Kaiser Permanente Hospital becaus.e she had injured her left shoulder. She told the doctor her shoulder had begun hurting after stretching it four or five days earlier. In February 2016, she had surgery on her shoulder to repair a torn rotator cuff.
About a year after the initial appointment, Rivera submitted a workers’ compensation claim for an injury to the same shoulder. One doctor examined her on October 19, 2016, and another examined her in August .cling bin. The second doctor reviewed Rivera’s prior medical records and concluded he did not believe her injury was work related. Her workers’ compensation claim was later rejected, but the County of Riverside was billed for her visits to the two doctors.
In July 2018, the Riverside County District Attorney’s Office filed a complaint charging Rivera with two felony counts of insurance fraud under Insurance Code section 1871.4, subdivision (a)(1) (count 1) and Penal Code section 550, subdivision (a)(1) (count 2). Rivera was arraigned in Riverside County Superior Court on September 21, 2018, pled not guilty,
On March 15, 2019, at the Riverside County Superior Court preliminary hearing. Kurtis Lackman, a workers’ compensation investigator, testified about his investigation into Rivera’s case.
Lackman said he began his investigation after the district attorney’s office received a referral from the county, which had already undertaken an investigation. He interviewed the doctors who examined Rivera after she made her workers’ compensation claim. He also interviewed Rivera. His testimony supported the facts set out above. After his testimony, the judge determined “it does appear that the offenses that are currently charged in Counts 1 and 2 have been committed. There’s sufficient cause to believe the defendant guilty of those particular offenses, so I will order that she be held to answer to same.”
The preliminary hearing resulted in a finding of probable cause, thus the People filed an information with the same charges now in Riverside County Superior Court., and Rivera pled not guilty at her arraignment.
A settlement conference was held in October 2021, two and a half years later. Rivera asked the judge to reduce the charges to misdemeanors under section 17(b) and grant her misdemeanor diversion under Penal Code section 1001.95 (section 1001.95), avoiding the need for a trial.
Later Rivera filed a formal motion to reduce the charges to misdemeanors and grant diversion, provided Rivera first paid restitution of approximately $20,000. The prosecutor objected, arguing the court did not have authority under section 17(b) to reduce the charges to misdemeanors until Rivera had pled guilty or been convicted.
The judge agreed with the defense that under the “Williamson Rule” the prosecution could not charge Rivera under sectioAn 550(a)(1) because the more specific section 550(a)(6) governs. The court granted the motion and set aside count 2.
On December 15, 2022, Rivera paid $20,000 in restitution and Riverside County Superior Court Judge Taylor reduced count 1 to a misdemeanor under section 17(b) and granted diversion under section 1001.95, with conditions that she perform 20 hours of community service and attend a life skills class.
The People filed a petition for a writ of mandate seeking to vacate the order setting aside the section 550(a)(1) count and the order reducing the Insurance Code count to a misdemeanor.overturn the order reducing count 1 to a misdemeanor and the order setting aside count 2.
The Court of Appeal agreed with Rivera and the trial court that the People were required to prosecute this workers’ compensation fraud case under the more specific section 550(a)(6). It therefore denied the People’s petition for a writ of mandate as to that order in the unpublished case of People v Superior Court (Rivera) -E080532 (August 2023)
The People charged Rivera under section 550(a)(1), which states it is unlawful to “[k]nowingly present or cause to be presented any false or fraudulent claim for the payment of a loss or injury, including payment of a loss or injury under a contract of insurance.” (Italics added.) The gravamen of the complaint and information was that Rivera knowingly presented a false claim for the payment of benefits available under the workers’ compensation law.
Rivera argues, and the Court of Appeal agreed, that the allegation against her also falls under section 550(a)(6), which makes it unlawful to “[k]nowingly make or cause to be made any false or fraudulent claim for payment of a health care benefit.” (Italics added.) Workers’ compensation benefits like funds paid to cover medical expenses are “health care benefits,” which means section 550(a)(6) applies specifically to her case.
The only differences between the two statutory provisions is that 550(a)(1) applies to payments for any losses or injuries and section 550(a)(6) applies to payments for health care benefits, a subset of the general category.
Rivera argued that the well established 1954 California “Williamson Rule” (In re Williamson, 43 Cal. 2d 651, 276 P.2d 593) justified the ruling of the trial court. The Williamson Rule is a legal doctrine in California criminal law that states that if a general statute includes the same conduct as a special statute, and thus conflicts with it, the special act will be considered as an exception to the general statute whether it was passed before or after such general enactment.
The Court of Appeal concluded that “It follows that the Williamson rule applies, and we should infer the Legislature intended that conduct like Rivera’s be prosecuted exclusively under section 550(a)(6).” … “The trial judge was correct to set aside the section 550(a)(1) count, and we will therefore deny the People’s petition for a writ of mandate as to that order.”