The Special Investigative Unit of RJN Investigations, Inc. was notified by the San Bernardino County District Attorney’s Office in regard to the arraignment of a school district’s instructional aide based upon a documented referral. In this particular case, the examiner detected significant red flag indicators and as such, authorized a surveillance level investigation. In the course of the surveillance investigation performed by the RJN SIU, over 2 hours of video evidence was obtained depicting the claimant performing a wide variety of outside physical activities, showing no restrictions or utilization of artificial support. In her subsequent Panel Qualified Medical Evaluation, the doctor wrote the following:
“As I indicated, due to the applicant’s subjective complaints of pain and her unwillingness to provide maximum effort on examination, her apparent limitations and range of motions are invalid…”
The video evidence was then provided to the PQME for review and comment in a supplemental report. The QME then made significant changes to his initial medical opinion and concluded the following in his report:
“I do not see that a re-evaluation of this patient would serve any specific purpose…”
In accordance with the regulation set forth by the California Department of Insurance, the case was then formally referred to their Fraud Division as well as to the San Bernardino County District Attorney’s Office District Office. Upon completion of a criminal investigation by the District Attorney’s Office, the claimant was charged with a felony in violation of Insurance Code Section 1871.4(a). The claimant was then arrested at her work site. At her arraignment on May 29th, 2019, the claimant entered a not guilty plea.
ABOUT R.J.N. SIU:
Formed in 1996, the SIU Division was created to assist California employers, small size insurance carriers and TPA firms in securing professional assistance so as to detect, investigate and prosecute insurance fraud. To date, the unit has trained well over 2,750 examiners and the documented referrals by this unit have resulted in over 195 convictions for workers’ compensation insurance fraud in California.