On February 14th, 2020, the Special Investigative Unit of RJN Investigations, Inc. was formally notified that the San Bernardino County District Attorney’s Office had filed four felony counts against the claimant. In this case, the claimant was employed as a full-time dental assistant. She alleged that she suffered a work related injury to her low back. At the time of filing her claim she denied pre-existing issues and injuries to her low back to her industrial treating physicians.
On July 23, 2018, in her Initial Injury/Illness Questionnaire, the claimant denied similar or the same symptoms before. On July 23, 2018, the claimant was seen by an industrial physician to whom she denied previous or preexisting back pain. On August 7, 2018, the claimant was seen by a second industrial physician to who she also denied prior back injuries. In addition, on August 22, 2018, the claimant denied prior injuries to the current area of complaint to her industrial orthopedic surgeon.
The claims examiner proactively subpoenaed the claimant’s prior medical records. Those records revealed the claimant filed a workers’ compensation claim for a cumulative trauma against her prior employer, which included multiple injuries including to her back. The records further showed that the claimant received significant medical treatment and eventually received a $73,000 settlement to resolve her prior claim. Moreover, during the claimant’s deposition taken in San Bernardino County the claimant admitted to filing a prior workers’ compensation claim, however she testified under penalty of perjury that her prior claim only involved her wrist.
In compliance with the regulations set forth by the California Department of Insurance, the RJN SIU formally referred the case to their Fraud Division as well as to the San Bernardino County District Attorney’s Office. Upon completion of their criminal investigation, the claimant was formally charged with four felony counts in violation of Insurance Code Section 1871.4(a)(1).
If convicted, the claimant could face imprisonment in a county jail for one year, or pursuant to subdivision (h) of Section 1170 of the Penal Code , for two, three, or five years, or by a fine not exceeding one hundred fifty thousand dollars ($150, 000) or double the value of the fraud, whichever is greater, or by both that imprisonment and fine. Restitution shall be ordered, including restitution for any medical evaluation or treatment services obtained or provided. The court shall determine the amount of restitution and the person or persons to whom the restitution shall be paid. A person convicted under this section may be charged the costs of investigation at the discretion of the court.
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 3,500 examiners and the documented referrals by this unit have resulted in over 195 convictions for workers’ compensation insurance fraud in California.