On March 24, 2021, the Special Investigative Unit of RJN Investigations, Inc. were notified the claimant entered a plea agreement with the Kern County District Attorney’s Office.
In this case, the claimant had filed a workers’ compensation claim against the employer for an injury to his left middle finger on October 11, 2018. The claimant received first aide care the same day and was discharged by October 18, 2018, with no restrictions. Almost a month later, the claimant returned for additional treatment with reported new and worsening symptoms. The claimant reported tremendous weakness in his left wrist and hand. In February 2019, the claimant’s statement was obtained in which he denied prior motor vehicle accidents or injuries to his left hand and wrist or upper extremity contrary to the claimant’s statement. Subpoenaed medical records from Van Guard Medical Group indicated the claimant was involved in a motor vehicle accident on October 21, 2018. On October 25, 2018, the claimant was seen in the emergency room as a result of the motor vehicle accident of 10/21/2018 where he complained of pain and numbness from the neck down his entire left arm. He told the ER he was unable to move his left arm since the motor vehicle accident on 10/21/2018. The claimant never mentioned he was involved in an industrial injury prior to this MVA to the ER. Additionally, medical records show the claimant had a history of left shoulder pain for over two years prior to the alleged injury on October 11, 2018.
As such and in compliance with the regulations set forth by the California Department of Insurance, the RJN SIU formally filed the case with their Fraud Division as well as with the Kern County District Attorney’s Office. Upon completion of their criminal investigation, the claimant was formally charged with five felony counts in violation of Insurance Code Section 1871,4(a)(1), one felony count in violation of Penal Code 550(a)(1) and one felony count in violation of Penal Code Section 550(b)(3). The claimant entered a plea bargain and pled no contest to one count of felony Penal Code 550(a)(1) and one count of felony Insurance Code 1871.4(a)(1). As part of the plea, the claimant was sentenced to two years in jail, ordered to pay restitution in the amount of $16,087.74, and ordered to pay a fine of $10,000.00.
ABOUT R.J.N. SIU:
Formed in 1996, the RJN SIU Division was created to assist California employers, 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 last three years, we have secured $ 701,686.00 in court ordered restitution on behalf of our valued clients.