On June 20th, 2019, the Special Investigative Unit of RJN Investigations, Inc. was notified regarding the successful prosecution in the case of People of California vs. S. Franco Jr. and M. Flores. In this case, the primary treating physician informed the claims examiner that the claimant had admitted to him that she never attended the vocational rehabilitation school that charged the claim file. In addition, she was told by the school that if anybody asks, she was to say that she attended the program, which was supposed to be comprised of 28 weeks of training. The claimant also stated that although she did not attend any training, the school supplied her with a certificate of completion and computer they said was valued at $4,000.00. The school, in turn, submitted billing in the amount of $9,926.00 to the claim file. During the SIU level investigation performed by RJN Investigations, Inc., additional claims were identified with a similar fact pattern. The RJN SIU then formally referred the case to the Los Angeles County District Attorney’s Office as well as to the Department of Insurance Fraud Division. As the investigation intensified, the Orange County District Attorney’s Office took the lead in the criminal investigation and prosecution of the operators of the school. Additional victims were identified, including that of Comp West, State Fund, ICW Group, Berkshire Hathaway and Travelers Insurance. Both defendants quickly accepted a court offer and pled no contest to all counts. They were then sentenced to 3 years formal probation and ordered to pay $88,000.00 in restitution to the insurers and $62,000.00 to cover the investigative cost to the California Department of Insurance Fraud Division.
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.