Lying About Prior Injuries Results in Three Felony Counts of Insurance Fraud

On December 6th, 2020, The Special Investigation Unit of RJN Investigations, Inc. was formally notified by California Department of Insurance Fraud Division as to the arraignment of the claimant based upon a documented referral submitted to their office. In this particular case, the claimant alleged to have suffered a work-related injury to his back while lifting a box. During the course of the claim, over $38,000 was spent on medical treatment and TTD benefits. The examiner proactively secured records pertaining to the claimant’s prior medical history which revealed a history of injury and complaints involving the same body part. The claimant made material misrepresentations during his AOE/COE statement when he denied any prior back injuries. Moreover, the claimant denied any previous injuries or complaints regarding his back to the treating doctor. In compliance with the regulations set forth by the California Department of Insurance, the RJN SIU formally referred this case to their Fraud Division as well as to the Los Angeles County District Attorney’s Office. Upon completion of a criminal investigation conducted by the Fraud Division, the claimant was formally charged with three felony counts in violation of Insurance Code Section 1871.4(a)(1). The claimant was subsequently arrested and at his criminal hearing on December 4th, 2020 entered a not guilty plea.


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 3,750 examiners and the documented referrals by this unit have resulted in over 200 convictions for workers’ compensation insurance fraud in California. In just the past 3 years we have secured $ 585,599.00 in court ordered restitution on behalf of our valued clients with the average claimant restitution being $ 24,399.00.

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