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Novo Nordisk and Others Challenge Medicare Drug Price Negotiations

Novo Nordisk, a major pharmaceutical company known for its diabetes and weight-loss drugs like NovoLog, Ozempic, and Wegovy, has been pushing back against a U.S. government program that allows Medicare to negotiate prices for certain high-cost prescription drugs. This program, part of the Inflation Reduction Act passed in 2022, aims to lower the cost of medications for millions of Americans, particularly seniors, by enabling Medicare to directly bargain with drugmakers for better prices. The first round of negotiations, which included some of Novo Nordisk’s insulin products, set new prices to take effect in 2026, while a second round targeting Ozempic and Wegovy is underway for 2027.

The company’s challenge stems from its belief that the negotiation process is unfair and oversteps legal boundaries. Novo Nordisk argues that the program forces them to accept lower prices under threat of hefty penalties, like steep taxes or losing access to Medicare and Medicaid markets, which they see as coercive rather than voluntary. They’ve raised concerns about the program violating constitutional protections, claiming it compels them to agree to prices that imply their drugs were overpriced before, which they argue infringes on free speech and due process. They also worry that lower prices could hurt their ability to fund research and development for new treatments.

On the other side, supporters of the program, including lawmakers and patient advocates, argue it’s a long-overdue step to make life-saving drugs more affordable. Medicare spends billions annually on medications like Novo Nordisk’s, with semaglutide-based drugs alone costing over $14 billion in a recent year. High drug prices can leave patients struggling to afford treatments, sometimes forcing tough choices between medicine and other essentials. The government contends that negotiating prices is a standard practice in other industries and countries, and the program is designed to balance affordability with innovation.

Novo Nordisk initially filed a lawsuit in 2023, challenging the program’s legality in a New Jersey federal court, but lost when a judge ruled participation was voluntary and didn’t violate their rights. They’ve since appealed to a higher court, arguing the program gives the government too much unchecked power. Meanwhile, they’ve reluctantly agreed to participate in both rounds of negotiations, likely to avoid penalties while their legal fight continues. The outcome of this challenge could shape how the U.S. tackles drug pricing, affecting patients, taxpayers, and the pharmaceutical industry for years to come.

Several other drugmakers have filed lawsuits challenging the Medicare drug price negotiation program under the Inflation Reduction Act, echoing concerns similar to Novo Nordisk’s about its legality and fairness. Companies like Merck, Bristol Myers Squibb, Johnson & Johnson, AstraZeneca, and Boehringer Ingelheim have all taken legal action, arguing the program violates constitutional protections, such as property rights and free speech, by forcing them to accept government-set prices under threat of penalties.

The pharmaceutical industry’s main trade group, PhRMA, along with organizations like the U.S. Chamber of Commerce, have also sued, claiming the program oversteps federal authority and could harm innovation. These cases, filed across various federal courts, have mostly been unsuccessful so far, with judges ruling that participation is voluntary since companies can opt out of Medicare entirely.

However, appeals are ongoing, and some companies hope conflicting rulings might push the issue to the Supreme Court. Despite the lawsuits, all affected drugmakers have participated in negotiations to avoid steep fines or losing access to Medicare’s massive market.

L.A. Judge Disqualified Post Trial and $10M FEHA Verdict Reversed

Plaintiff Sabrena Odom was and still is a tenured professor at Southwest College. She began as an adjunct, and in 2005 was hired full time, working 50/50 as an English instructor and as director of the Student Success Center, which offered tutoring and workshops to enable student learning.

Defendants are the District and Dr. Irvin, the alleged harasser. Dr. Irvin joined Southwest College in 2016 as vice president of student services. He had been an officer with the Los Angeles Police Department for 13 years, until he retired in 1998, 18 years before he joined Southwest College. After leaving the police department, he began a career in community counseling and worked at several community colleges in southern California. He earned his Ph.D. in 2007.

In October 2018, Odom filed a complaint for damages, alleging sexual harassment; failure to investigate and prevent sexual harassment; retaliation; and negligent hiring, supervision and retention, in violation of the Fair Employment and Housing Act (FEHA; Gov. Code, § 12940 et seq.), against defendants Los Angeles Community College District and Howard Irvin, then the vice president of student services at Los Angeles Southwest College, a community college in the District.

Plaintiff testified that the sexual harassment began in February 2017 and continued for about eight months. In early November 2017, plaintiff went to Denise Noldon, the interim president of Southwest College, and told her she was being sexually harassed by Dr. Irvin, had not complied with his wishes, and felt she was being retaliated against “with an attack against my program as well as my staff.” Plaintiff testified that nothing happened in response to her complaint.

During the summer of 2017, someone had slipped an article from The Los Angeles Times under her door, with the handwritten words, “Watch Out.” (There were actually two articles, one dated Feb. 25, 1998, and the other dated Oct. 30, 1997.) Plaintiff stated that the article “detailed Dr. Irvin’s past as an LAPD officer and his conviction of sexual assault. I was already uneasy around him, but after reading the article, I became frightened whenever he was around. I didn’t want to become a victim of his like the woman in the article. One day during a meeting with Dr. Irvin, I asked him if he carried a gun. His response was, ‘No, but I can get to it when I need it.’ Another time, I asked him the same question and he said, ‘Of course.’ “

During her trial testimony, plaintiff’s counsel asked plaintiff to explain more about The Times’s articles. Defense counsel objected on hearsay grounds. The court stated, “Well, the L.A. Times is not being admitted for the truth. What the L.A. Times article says is being admitted for her reaction, not admitted for the truth, so it’s overruled.”

Judge Robert S. Draper presided over a three-week trial in October 2022. There were more than 20 witnesses.Dr. Irvin’s criminal defense attorney testified Dr. Irvin was never convicted of any sex crime, and there was no evidence at trial to support plaintiff’s belief that he had been.

After deliberating for less than a day, the jury found in favor of plaintiff on each of her four claims. As to the District, the jury awarded plaintiff $8.5 million in noneconomic damages ($7 million for past mental suffering and emotional distress and $1.5 million for future mental suffering and emotional distress). As to Dr. Irvin, the jury awarded $1.5 million in noneconomic damages for past mental suffering and emotional distress. The jury found by clear and convincing evidence that Dr. Irvin acted with malice or oppression, but in the punitive damages phase of the trial, the jury declined to award any damages.

Defendants moved for partial judgment notwithstanding the verdict, or in the alternative for remittitur, based on excessive damages. “The hearing on defendants’ motions was held on February 15, 2023. The trial court made comments at the hearing, and later in chambers, reflecting his personal feelings and perspectives about societal and civil rights advances of Black Americans and the progress our society has made respecting women in the workplace since he was a college student and then a young attorney decades ago. At times during the hearing, Judge Draper appeared to become emotional and repeatedly described the personal effect the testimony had on him as a grandfather.”

The Court of Appeal reversed the judgment and ordered a new trial in the published case of Odom v L.A. Community College District – -B327997 (April 2025) “not for lack of substantial evidence, but for prejudicial errors in the admission of irrelevant and damaging “me-too” evidence from a witness who was not similarly situated to plaintiff, and for the equally prejudicial and erroneous admission of 20-year-old newspaper articles and other evidence of the alleged harasser’s misdemeanor convictions.”

The Court of Appeal also wrote “This is an unusual case, due to the significant arbitrary and prejudicial evidentiary rulings of the judge presiding over the trial. After the judgment was entered, defendants filed motions for a new trial (or in the alternative a remittitur) and for partial judgment notwithstanding the verdict (JNOV) (or in the alternative for remittitur). At the hearing on those motions, which were denied, the trial judge initiated extended, bizarre personal comments on racial matters with newly substituted defense counsel (the only Black woman in the courtroom), despite there being no racial issue of any kind in the case. Defendants filed a motion to disqualify the judge for cause and to void his rulings on the motions. After writ proceedings and referral to a neutral judge, the trial judge was disqualified and his rulings on the postjudgment motions were voided.”

“On this appeal from the judgment, we need not decide whether the trial judge’s prejudicially erroneous evidentiary rulings during the trial were motivated, in part, as defendants contend, by “persistent racial and gender bias.” It seems clear the judge’s rulings were motivated by personal opinions untethered to the rules of evidence. Whatever his motivations may have been, the judge admitted inflammatory evidence without consideration of the evidentiary rules, with undeniable prejudicial effect, thus preventing a fair trial. We accordingly reverse the judgment and order a new trial.”

During the post trial hearing, “Judge Draper made many inappropriate remarks, including comments using racial terms. For example, Judge Draper stated that plaintiff and Dr. Irvin came from the same neighborhood: ‘And I use the term that my wife says is not politically acceptable. I think they are politically acceptable, because I use terms like coal black and light brown because I don’t think those are bad terms.’ ”

Judge Draper’s statements at the hearing led to a motion by defendants on March 3, 2023, to disqualify him for cause. Judge Draper issued a lengthy “recusal order” finding there were no legal grounds for disqualification for cause but recusing himself from further proceedings in the case.

Defendants sought writ review, and this court directed the superior court to refer the disqualification motion to a neutral judge. On October 16, 2023, Orange County Superior Court Judge Cheri Pham disqualified Judge Draper, stating that the evidence defendants submitted “establishes that during the February 15, 2023 hearing, Judge Robert S. Draper made several irrelevant and inappropriate comments about race and gender. Defendants’ attorney was the only African American person in the courtroom. Under these circumstances, and on the record presented, a person aware of the facts might reasonably entertain a doubt whether Judge Draper would be impartial.” Judge Pham also observed that, in response to our alternative writ, Judge Draper had vacated his recusal orders, and there was no verified answer to defendant’s disqualification motion; so the judge was deemed to have consented to his disqualification.

DWC Releases 2024 Independent Medical Review (IMR) Report

In September 2012, Governor Brown signed SB 863 into law. This reform of the workers’ compensation system in California included adoption of the IMR process, which went into effect on January 1, 2013, for injuries that occurred in 2013. On July 1, 2013, IMR was available to all injured workers regardless of their dates of injury.

The Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) have posted an annual report on the Department’s Independent Medical Review (IMR) program. IMR is the medical dispute resolution process for the state’s workers’ compensation system that resolves disputes over medical treatment for injured workers. The report describes IMR program activity in 2024, the twelfth year since the program was implemented.

The Independent Medical Review Organization (IMRO) administering the program, Maximus Federal Services, Inc., received 199,651 IMR applications, and issued 141,621 Final Determination Letters, each addressing one or more medical necessity disputes. Throughout the year, the IMRO issued decisions, on average, six to seven days after receipt of all medical records.

Some highlights of the report are as follows:

– – Nearly 90% of all unique IMR filings were deemed eligible for review, slightly less than the annual percentage for those filed in 2023.
– – Pharmaceutical requests accounted for 33% of all treatment requests sent for IMR, a slightly higher proportion of total service requests than in previous years.
– – Opioids comprised 24% of all pharmaceutical requests.
– – Treatment request denials were overturned at an overall rate of 12.7%, an increase from the previous year (10.2%). The denials that were overturned most often were for evaluation and management services, followed by other programs such as Functional Restoration program, Brain Injury program, Weight loss program, and behavioral and mental health service.
– – Guidelines contained in the Medical Treatment Utilization Schedule continue to serve as the primary resource for the determination of medical necessity.

Expert reviewers may hold licenses to practice in any of the 50 states. Reviewers licensed in California evaluated 81% of the decisions in 2024. This is a lesser proportion than in the previous years, when reviewers licensed in the state evaluated 83% of the decisions issued in 2023, and 87% of the decisions issued in 2022.

Filing Claim in Employers’ Bankruptcy Not Required for UEBTF Benefits

Adan Alvarez was employed on June 11, 2015 as a mover by Victor Manuel Martinez, individually and doing business as Bob Williams Moving, and Justine Marie Martinez, individually and doing business as Tristar Moving, and claimed to have suffered injury to multiple areas. It was stipulated by the parties that the employer was uninsured.

After a trial, the WCJ found applicant failed to file a proof of claim in the bankruptcy proceeding against alleged employers Victor Manuel Martinez and Justine Marie Martinez. Applicant did not strictly meet the statutory conditions that would render the Uninsured Employers Fund (UEF) liable for payment, and is now enjoined from obtaining an award in a workers’ compensation proceeding enforceable against Victor Manuel Martinez and Justine Marie Martinez personally or the UEF. Therefore, the undersigned WCJ found good cause to dismiss applicant’s claim with prejudice.

The WCAB granted reconsideration, and reversed in the panel decision of Alvarez-1 v Bob Williams Moving – ADJ10037291 (January 2025).

Applicant argued in Alvarez1 that the trial court’s reliance in Ortiz v. Workers’ Comp. Appeals Bd. (1992) 4 Cal.App.4th 392 is misplaced because the employee in Ortiz, unlike applicant here, had an award of temporary disability and reimbursement for medical treatment. Applicant further argues laches because UEBTF participated in discovery and was aware of the bankruptcy court’s lifting of the automatic stay and applicant’s failure to file a proof of claim in the bankruptcy proceedings. Applicant contends UEBTF should have alerted applicant of the requirements set forth in Ortiz.

The Ortiz court stated: “Assuming the prerequisites to payment by the UEF have been met, if a findings and award in a workers’ compensation proceeding issues prior to a discharge of an employee’s claim in bankruptcy, the UEF would pay the award, become a creditor, and thus be able to file its own proof of claim in the bankruptcy proceeding.” And “The discharge in bankruptcy operates as an injunction prohibiting any proceeding against the employer for personal liability based on the award, however, including the UEF’s right to seek reimbursement pursuant to Labor Code section 3717.”

The WCAB panel noted “The Ortiz court, however, did not address whether an employee is required to file a proof of claim in the bankruptcy proceedings in this situation-when there is no workers’ compensation award before the discharge.” And it went on to find Slali v. Ruiz (2002) 282 B.R. 225 [67 Cal.Comp.Cases 634] instructive.

“In Ruiz, just as in this case, the employee did not file a proof of claim in the Chapter 7 bankruptcy proceedings of the employers. (Id. at p. 636.) The bankruptcy court entered discharges in favor of both employers as there were no assets to distribute. (Ibid.) The employee then petitioned for relief in the bankruptcy proceedings in order to pursue his workers’ compensation claims. (Ibid.) The bankruptcy court provided such relief and entered an order that (1) allowed the employee to pursue an award against the employers in his workers’ compensation case; (2) no personal liability on behalf of the employers to the employee would be created; (3) the employee would not be allowed to seek satisfaction of any award against the employers absent further orders from the bankruptcy court; (4) the employee’s claim remained open and pending before the WCAB and had not been resolved or decided; and (5) the employers’ participation in the litigation before the WCAB would not be affected by the bankruptcy order. (Ibid.)”

The bankruptcy court’s order was appealed to the United States District Court, which affirmed the bankruptcy court’s order.The District Court further explained that although it does not believe that the employee needed relief from the discharge injunction, it was prudent for the employee to seek such relief to serve as a clarification regarding the scope of the discharge injunction and avoid conflict between the workers’ compensation and bankruptcy proceedings. (Ruiz at p. 638.)

Ruiz instructs us that a failure to file a claim of proof in the bankruptcy proceedings when an employee does not yet have a compensation award from which to file a proof of claim is not fatal. We, therefore, conclude that the trial court’s finding that applicant here is enjoined from pursuing his workers’ compensation claim was in error.”

The Uninsured Employers Benefits Trust Fund (UEBTF) Petition for Reconsideration of Alvarez-1 was denied in In Alvarez-2 v Bob Williams Moving ADJ10037291 (April 2025),

In Alvarez-2 UEBTF contends that the WCAB failed to appreciate the difference between a Chapter 7 asset bankruptcy and a Chapter 7 no asset bankruptcy. According to UEBTF, in the former, a creditor such as applicant is required to file a proof of claim in a bankruptcy proceeding and failure to do so enjoins applicant from later seeking payment from UEBTF. In the latter, a failure to file a proof of claim is not fatal as demonstrated in In re Manuel D. Slali (Bankr. C.D.Cal. 2002) 282 B.R. 225 [67 Cal.Comp.Cases 634]. UEBTF contends that the underlying bankruptcy proceeding here was a Chapter 7 asset bankruptcy and, therefore, applicant was required to file a proof of claim in order to later seek payment from UEBTF.\

UEBFT cites to Duncan v. Workers Compensation Appeals Bd. (1998) 63 Cal. Comp. Cases 309 [1998 Cal. Wrk. Comp. LEXIS 4510] to support its argument. In Duncan, the WCJ found that in order to reinstate a workers’ compensation award, applicant “must obtain a modification of the discharge order in bankruptcy allowing a personal judgment to be entered against the uninsured employer.” (Duncan, at p. 310.)

After reviewing Duncan, the WCAB concluded in Alvarez-2 that the “Duncan court simply held that in a no asset case, it was not necessary to seek modification of the discharge injunctions in the bankruptcy court. Duncan does not stand for the proposition that a failure to file a proof of claim in the bankruptcy proceeding, whether it be an asset or no asset proceeding, enjoins the employee from later seeing payment from UEBTF. As such, we affirm our January 3, 2025 Opinion allowing applicant’s workers’ compensation claim to proceed despite his failure to file a proof of claim in the underlying bankruptcy proceeding.

WCAB Applies Amended L.C. 4707(c) Retroactivity

Applicants filed an Application for Adjudication, seeking workers’ compensation benefits in connection with the death of decedent Mathew Brabo, who passed away on February 1, 2022. The claim was settled via Stipulations with Request for Award, and an Award issued on December 14, 2022. His employer was the California Department of Forestry Region IV.

As part of the stipulations, the parties noted that, pursuant to Labor Code section 4707, subdivision (a) as it then existed, applicants were not eligible for most workers’ compensation death benefits because they received the CalPERS Special Death Benefit.

On January 1, 2024, section 4707 was amended to add subdivision (c), which removed this limit on workers compensation death benefits for a number of state safety members including firefighters for the Department of Forestry and Fire Protection who are members of Bargaining Unit 8 of the Public Employees’ Retirement System.

This amendment specified that “This subdivision shall be applied retroactively to January 1, 2019, for injuries not previously claimed or resolved, and shall not supersede any statutes of limitations otherwise provided by the Labor Code.’

On September 3, 2024, applicants filed a Petition to Reopen the stipulated award, seeking to amend the award to include the death benefits they contend that they are now eligible for in light of the amendments to section 4707. The WCJ issued his decision, finding that applicants were not eligible for increased death benefits. The WCJ’s decision rested upon his interpretation that the phrase “applied retroactively to January 1, 2019, for injuries not previously claimed or resolved” unambiguously referred to injuries or claims not resolved prior to January 1, 2024, the date of the subdivision’s enactment.

Since applicants’ claim was resolved on December 14, 2022, before January 1, 2024, the WCJ concluded that applicants were not entitled to increased death benefits under the statute.

The WCAB panel granted Reconsideration, and substituted a new order finding that applicants are entitled to amend their award pursuant to sections 5803 and 5804, with the precise amount of benefits awardable deferred for determination at the trial level in the case of Bravo v California Department of Forestry Region IV – ADJ15915611 (March 2025).

The WCAB panel noted that it was “presented with a pure question of law: whether death claims brought by eligible applicants that were resolved after January 1, 2019, but prior to January 1, 2024, may be amended to award the increased death benefits now provided for by that subdivision.”

“We are directed to interpret statutory language “consistently with its intended purpose, and harmonized within the statutory framework as a whole.” (Alvarez v. Workers’ Comp. Appeals Bd. (2010) 187 Cal.App.4th 575, 585 [75 Cal. Comp. Cases 817].)”

And they wrote “we cannot agree with the WCJ that the clause “for injuries not previously claimed or resolved” unambiguously refers to claims and injures not resolved prior to the effective date of the statute, rather than prior to January 1, 2019, the date which immediately precedes it.”

“Happily, it does not appear necessary to definitively resolve this conundrum because, for the reasons outlined below, applicants appear entitled to amend the award to include increased death benefits no matter how the clause in question is interpreted. This is because the Labor Code, in its wisdom, allows for the amendment of an award pursuant to sections 5803 and 5804, as long as five years have not passed from the date of injury and good cause exists for the amendment. (§ 5803, 5804.)’

‘Moreover, it is well-established that a change in the law constitutes good cause to amend an award pursuant to section 5803. (Fireman’s Fund Ins. Co. v. Workers’ Comp. Appeals Bd. (2010) 181 Cal.App.4th 752, 768; see also Brannen v. Workers’ Comp. Appeals Bd. (1996) 46 Cal.App.4th 377, 382.).”

“Accordingly, even if the clause “for injuries not previously claimed or resolved” is meant to refer to injuries not claimed or resolved prior to January 1, 2024, rather than January 1, 2019, applicants are still entitled to amend their award to reflect the increased benefits due under the statute based upon sections 5803 and 5804. This conclusion is reinforced by the final clause of the sentence, specifying that the subdivision “shall not supersede any statutes of limitations otherwise provided by the Labor Code.” Section 5804 contains one such statute of limitations, and the Legislature’s reference shows it was cognizant of such statutes of limitations and did not intend to abrogate them.”

March 31, 2025 – News Podcast


Rene Thomas Folse, JD, Ph.D. is the host for this edition which reports on the following news stories: WCAB Rules UR Denial Needs Adequate Medical History Records. Workers’ Comp Claim Does Not Toll FEHA Statute of Limitations. SoCal Medical Group to Pay $62M to Settle False Claims Lawsuit. Bay Area Tow Truck Auto Fraud Conspiracies – Out of Control. Jury Convicts San Diego Attorney for Fraud Schemes. Treatment Center Operator Convicted for $2.9M in Kickbacks. Carson Tahoe Health System to Pay $8.8M for Unlawful Benefits. CWCI New Hire Notices Are Updated for 2025.

After Supreme Ct. Remand, CSU Need Not Reimburse Employees

When the COVID-19 pandemic struck, the Board of Trustees of the California State University (CSU) directed that instruction be provided remotely. To comply with this directive, Patrick Krug, a biology professor at California State University Los Angeles, incurred expenses for a computer and other equipment and necessities which CSU declined to reimburse.

Krug sued CSU on behalf of himself and similarly situated faculty, alleging Labor Code section 2802 obligated CSU to reimburse its employees for necessary work-related expenses. CSU demurred, arguing that as a department of the state it enjoyed broad exemption from Labor Code provisions that infringe on its sovereign powers. Krug appealed from a judgment of dismissal entered after the trial court sustained CSU’s demurrer without leave to amend.

In August 2023 the Court of Appeal affirmed the trial court in the Published case of Krug v. Board of Trustees of the Cal. State Univ – B320588 (August 2023).

The California Supreme Court granted review of Krug pending its decision in Stone v. Alameda Health System (2024) 16 Cal.5th 1040 (Stone), after which it remanded the matter back to the Court of Appeal for reconsideration in light of its holding in that case.

After reconsideration in light of Stone, the Court of Appeal again affirmed the trial judgment in the second published opinion of Krug v. Board of Trustees of the Cal. State Univ B320588A (April 2025)

The Stone Court examined the language, structure, and history of the statutes and wage order at issue to determine whether the Legislature intended to impose their requirements on public employers. Using this framework, the Court addressed the text and history of relevant Labor Code and wage order provisions to concluded that the hospital was exempt from the employees’ claims.

On remand from the Supreme Court, the Court of Appeal on re-review of Krug followed Stone’s analytical framework to determine whether the Legislature intended to exclude public entity employers from the employment expense reimbursement obligations at issue here.

It then concluded that the statutory structure evinces positive indicia that the Legislature intended to exclude government employers from the terms of section 2802. The legislative history of section 2802 also supports the conclusion that the Legislature intended to exclude government employers from its terms. Later legislative history was also in accord when section 2802 was amended in 2000 by Senate Bill No. 1305 (SB 1305).

However no case has applied the reimbursement obligations set forth in section 2802 to a public employer.

“In sum, although the language of section 2802 is silent on whether “employer” denotes both public and private entities, the statutory structure and legislative history provide positive indicia of legislative intent to exclude public employers from the provision’s reimbursement obligations.” … “Therefore, we conclude section 2802 does not obligate CSU to reimburse employees for work-related expenses, without the need to resort to interpretive maxims.”

LA Couple Sentenced for $2.3M WC Premium Fraud

John Nemandoust, 70, and Annette Assil, 62, a Los Angeles couple, were sentenced after a California Department of Insurance investigation found they underreported more than $21 million in employee payroll for their delivery companies.

Nemandoust was sentenced to 60 days in county jail, while Assil was sentenced to 30 days. The pair were sentenced to 10 years of felony probation and also ordered to pay $2,254,748 in restitution for unpaid workers’ compensation insurance premiums.

The Department launched an investigation into A-1 Valley Services, Prompt Delivery, and Affordable Messenger, the three companies the couple owned, after receiving information that two of the companies were uninsured. The investigation revealed that between 2013 and 2017, the couple only obtained workers’ compensation coverage for Valley Services employees, while leaving Prompt Delivery and Affordable Messenger uninsured.

When employees from the uninsured companies sustained work-related injuries, they fraudulently filed claims under Valley Services’ policy, concealing the lack of coverage and misclassifying their workforce. Over the four-year period, at least 20 uninsured employees had claims improperly filed under Valley Services’ policy.

A forensic audit found that the companies’ combined gross payroll exceeded $25 million, while they only reported approximately $1.4 million to their insurance carrier—resulting in the $21 million payroll underreporting. This scheme allowed the couple to avoid paying approximately $3 million in workers’ compensation insurance premiums.

“By misleading their insurance carriers, these business owners created an unfair advantage over their competitors and put their employees at risk,” said California Insurance Commissioner Ricardo Lara. “This sentence ensures they are held accountable and must repay the stolen premiums.”

The Los Angeles County District Attorney’s Office prosecuted the case.

Legal Aid Lawsuit Forces EDD to Fix Broken UI Notification System

Legal Aid at Work (LAAW) reached a settlement agreement with the California Employment Development Department (EDD), the state agency responsible for administering unemployment insurance for millions of people who work in California. The case involves a lawsuit challenging the legality of EDD’s policies for informing unemployment insurance claimants of determinations that the claimant cannot receive benefits or needs to repay benefits that the claimant has already received.

The agreement, which still needs court approval, will dramatically increase the likelihood unemployment insurance claimants will promptly learn about negative decisions, understand them, and know how to challenge them. Among other things, the settlement will require the EDD to start sending information about its decisions by email and text message, and will require the EDD to rewrite its notices so they are written at an eighth-grade level.

During the COVID-19 pandemic, millions of Californians accessed unemployment insurance benefits, and the state paid out nearly $25 billion in benefits in 2020 alone. California’s Legislative Analyst’s Office has estimated that between $500 million and $1 billion in benefits go unreceived each year because the EDD improperly denies claims. Other claimants are ordered to repay benefits when they are retroactively deemed ineligible for benefits. These decisions, which can order claimants to repay $10,000 or more in benefits, are often financially crippling. And the decisions are often wrong. Claimants who appeal EDD’s decisions have historically been able to get those decisions reversed on appeal over 50 percent of the time, according to the same LAO report.

The lawsuit, Okamura v. Employment Development Department, was filed in Alameda County Superior Court. It argues that EDD failed to properly notify claimants when their benefits were denied, when they owed money back, or when they were accused of fraud. As noted in the Complaint, some claimants only learned about these decisions after their wages were garnished or their tax refunds were seized. Even when claimants did receive notices, the notices were so confusing that they didn’t understand why they were being charged with an overpayment, or realize that they could challenge the EDD’s decision.

EDD will make many important changes to improve how it notifies people about unemployment benefit decisions, including:

– – Expanded Digital Notifications – EDD will soon send emails, text messages, and online alerts to make sure people know about benefit denials and overpayments. Currently, the EDD only sends these notices to claimants by mail, even though most of the unemployment insurance process is done online and over the phone.
– – Creating Easier-to-Understand Notices – EDD has agreed that notices revised as part of its longer-term modernization effort will be rewritten at an 8th-grade reading level. Currently, notices are drafted at a college-level reading level, making them difficult to understand for most claimants.
– – Using Address Verification Tools – EDD will implement a system to verify claimants’ mailing addresses by cross-checking the National Registry of New Hires, and eventually the United States Postal Service’s National Change of Address database. These changes will reduce instances of lost or delayed communication, especially when the EDD sends notices to claimants months or years after they stopped collecting unemployment insurance benefits.
– – Clearer Information About EDD’s Decision – Notices will provide additional information on why benefits were denied or overpaid. Currently, notices only provide limited information about the EDD’s decision, leaving claimants guessing about why they were denied or required to pay back benefits.
– – Disclosure About Possibility of Waiver of Overpayment – Importantly, the EDD will also start telling claimants who receive Notices of Overpayment that some claimants are eligible for a waiver of the overpayment. On appeal, the California Unemployment Insurance Appeals Board regularly decides that an overpayment must be waived, and claimants do not need to pay back benefits they were not eligible to receive.

Even though this lawsuit was filed as a potential class action, the settlement only requires the four individual named plaintiffs and Legal Aid at Work, an institutional plaintiff, to release their claims. The lawsuit does not affect other claimants’ right to file their own legal claims if they have been affected by EDD’s practices in the past.

The motion for settlement approval and entry of judgment was filed in Alameda County Superior Court. If approved, EDD will begin implementing the agreed-upon changes over the next year.

San Diego Plumbing Contractor Sentenced for SCIF Premium Fraud

The the San Diego County District Attorney’s Office announced that Daniela G. Birdwell, owner of GPS Plumbing, pleaded guilty to workers’ compensation insurance premium fraud.

She has been sentenced to two year felony probation plus 320 hours of community service. She has also been ordered to pay $1,030,062 to the State Compensation Insurance Fund in restitution of underpaid workers’ compensation premiums. She will be required to pay this restitution in payments of $10,000 per month.

The fraud was first discovered when a State Fund special investigation unit saw noticeable differences between wages the company reported to the Employment Development Department and wages reported to the State Fund during policy audits.

The report of suspected fraud was submitted to the district attorney’s office and the Department of Insurance for investigation by the SCIF Special Investigation Unit.

“Employers who engage in premium fraud are not only breaking the law, they also gain an unfair advantage over their competitors,” District Attorney Stephan said. “The dedicated investigators and prosecutors in our Insurance Fraud Division will continue to investigate this type of fraud to hold businesses accountable, protect employees, and level the playing field for law abiding companies.”

According to Forbes 2025 Insurance Fraud Statistics, between 1.3 and 2.1 million workers were misclassified or paid off the books each month in 2020, a tactic used to lower workers’ compensation premiums.

A comprehensive study of Fraud in Workers’ Compensation Payroll Reporting was published in 2009 by the Fraud Assessment Commission. The Fraud Assessment Commission (FAC) asked the authors to extend the prior study data to include the period from 2002 through 2005. The FAC also requested that the University examine whether employers were increasing the use of non-standard employment contracts (e.g., independent contractors) to avoid the high workers compensation rates.

The follow up audit showed that “despite auditing by insurers and the WCIRB and penalties for fraudulent reporting imposed by statute and regulation, dishonest employers are significantly and substantially under-reporting or misreporting payroll to insurers. In so doing, dishonest employers are gaining unfair advantage relative to honest employers in two ways. First, dishonest employers shift part premium payment onto honest employers. Second, by avoiding premiums, dishonest employers can price their products or services unfairly relative to honest employers.”

An important aspect of these findings is that under-reporting and misreporting of payroll results in premium rates in highest-risk class codes that are several times the rate the employers would experience under full reporting. In these classes, honest employers are paying substantially more, more than double, for workers’ compensation than actual experience would imply is accurate. This is a substantial transfer of income and profits from honest employer to dishonest employers. This transfer compounds the competitive disadvantage faced by honest employers. It is important for the state to improve reporting in order to level the playing field for employers that try to play by the rules.”