On December 13th, 2021, the Special Investigative Unit of RJN Investigations, Inc., learned that the Sonoma County District Attorney’s Office had filed felony insurance charges based upon a documented referral submitted to their attention. In this particular case, the claimant attended her QME appointment at which time she complained of pain and swelling in her left ankle, constant pain in both knees and constant pain to the left lower extremities. She reported that she limps all the time and utilizes a cane in order to ambulate. The RJN SIU secured extensive video evidence of the claimant attending this appointment and utilizing the cane. Upon exiting the QME examination, the claimant was followed to her residence where she was observed performing manual labor and yardwork while showing no restrictions, hesitation or utilization of the cane. While performing the yardwork, the claimant was repeatedly bending at the waist, lifting and carrying wood boards, hacking weeds with an ax, carrying a pallet and walking freely. The video evidence secured was then provided to the QME for review and comment. Upon review of the subrosa video evidence, the QME made significant changes in his medical reporting. In compliance with the regulations set forth by the California Department of Insurance, the case was then formally referred by the RJN SIU to their Fraud Division as well as to the Sonoma County District Attorney’s Office. Upon completion of a criminal investigation performed by the Sonoma County District Attorney’s Office, the claimant was formally charged with one felony count of Insurance Code Section 1871.4(a)(1) and one felony count of Penal Code Section 550(a)(1). The claimant is scheduled to attend her criminal hearing on December 15th, 2021 at the Sonoma County Superior Court.
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 4,000 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 $ 930,236.00 in court ordered restitution on behalf of our valued clients.
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