On January 9th, 2023, the Special Investigative Unit of RJN Investigations, Inc. established that felony insurance fraud charges were filed based upon the submission of a documented fraud referral. In this case, the claimant worked as a groundskeeper for a recreational park.
The claimant alleged an injury to the left foot due to constant walking. From the beginning of his treatment, the claimant denied any recreational activities to his industrial care physician. He also denied prior injury or treatment to his left foot. The claims examiner proactively assigned the claim to the RJN SIU to conduct surveillance. Surveillance video obtained contradicted the claimant’s statement to his industrial treating physicians when he was videotaped surfing on several occasions. When the surveillance still photos were shown to the claimant’s treating physician, the doctor determined that if the claimant was able to surf and participate in recreational activities, he could also go back to work for the insured without restrictions, and thus, the doctor immediately changed the claimant’s work status. Additionally, subpoenaed records showed the claimant a work injury in 1999, when he fell approximately 8 feet landing on a slope. As a result, he had orthopedic treatment and surgery followed by physical therapy for approximately 6 months.
After completing the SIU level investigation 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 Ventura County District Attorney’s Office. Upon completion of their criminal investigation, the claimant was formally charged with three felony counts in violation of Insurance Code Section 1871.4(a)(1). The claimant is set for arraignment on January 19, 2023.
ABOUT R.J.N. SIU:
Formed in 1996, the RJN SIU Division was created to assist California employers, governmental agencies, 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 4000 examiners and the documented referrals by this unit have resulted in over 215 convictions for workers’ compensation insurance fraud in California. In just the last 4 years, we have secured $1,402,030.00 in court ordered restitution on behalf of our valued clients.