In Home Care Provider Charged with Felony Insurance Fraud

On June 12th, 2020, the Special Investigative Unit of RJN Investigations, Inc. was notified by the Los Angeles County District Attorney’s Office regarding the filing of felony insurance fraud charges. In this case, the claimant worked as an in-home care provider. He alleged that he had injured his back as a result of moving a patient from a wheelchair onto a bed. While undergoing medical treatment, the claimant stated that he needed a cane in order to ambulate. Given the detection of red flag indicators, the claims examiner proactively authorized the RJN SIU to perform surveillance. This surveillance found the claimant to ambulate without a cane, but at his deposition, he showed up with a back brace and a cane. The subrosa video evidence was then provided to the QME for review and comment. In his report, it states in part the following:

“The extensive subrosa video footage that I was sent demonstrates Mr. Lopez performing a variety of physical activities over several different days. The physical activities include driving, sitting, standing, walking, bending, squatting, reaching overhead, and pushing and grasping…The subrosa video footage is in contrast and he is visualized performing physical activities in the subrosa footage with no apparent difficulty which is better than what he reported in the initial PQME evaluation and exhibited during the examination. My reporting on this case has changed as a result of this additional information…”

In accordance with the regulations set forth by the California Department of Insurance, the case was formally referred to their Fraud Division as well as to the Los Angeles County District Attorney’s Office. Upon completion of the criminal investigation performed by the Los Angeles County District Attorney’s Office, the claimant was formally charged with three felony counts of insurance fraud. His arraignment is now scheduled to take place on July 8th, 2020.

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.


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