On March 8th, 2021, the Special Investigative Unit of RJN Investigations, Inc. was informed that the Sacramento County District Attorney’s Office had formally filed felony insurance fraud charges based upon a documented referral submitted.
In this particular case, the claimant worked as an Emergency Department Technician at a local hospital. The claimant alleged to have suffered a work-related injury to various body parts while performing her employment duties. The claimant was given work restrictions of no driving, no bending at the waist, no twisting, no reaching above shoulder level, no lifting, carrying, pushing, pulling more than 5 lbs. Given the extent of the restrictions, the examiner requested the RJN SIU to conduct a surveillance level investigation. In the course of that surveillance, the claimant was found to be engaged in numerous outside physical activities which contradicted the given restrictions. The surveillance video evidence was secured over several different dates, including on the date of the claimant’s AME appointment. On that date, the claimant utilized an artificial support that was never observed before.
The video evidence was subsequently provided to the AME for review and comment in supplemental report. In that report, the AME states in part the following:
“With reasonable medical probability, the surveillance of Ms. XXX performing normal activities of a normal woman were in direct contrast to Ms. XXX presentation on my medical examination where she presented with so much pain that all she could do was move and cry if she tried to move…”
In compliance with the regulations set forth by the California Department of Insurance, the RJN SIU then formally filed this case with their Fraud Division as well as with the Sacramento County District Attorney’s Office Workers’ Compensation Fraud Unit. Upon completion of their criminal investigation, the claimant was formally charged with a felony in violation of Insurance Code Section 1871.4(a)(1) as well as a felony in violation of Penal Code Section 550(b)(3). At this time, there is an active felony arrest warrant on this case.
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 $685,599.00 in court ordered restitution on behalf of our valued clients.