On March 10th, 2023, the Special Investigative Unit of RJN Investigations, Inc. was notified of the successful prosecution of two sisters in Sonoma County. In this case, the claimant alleges to have suffered a seizure and claimed it to be work related. As her medical condition deteriorated, her sister acted as a caregiver and would assist the claimant in her activities of daily living and for transportation. The claimant’s sister also spoke on behalf of the claimant during medical evaluations, examinations, and multiple depositions. Surveillance performed by RJN SIU secured significant video evidence showing the claimant engaging in various activities in direct contradiction to her statements provided to her treating doctors as well as during her deposition. During the Surveillance, the claimant was also found to be driving unassisted. The video was subsequently provided to the Panel QME who issued a supplemental report that stated the following, “She says this is a cognitive problem that happened within several weeks of the injury and that she’s been this way for years, and you just don’t see that kind of functioning – I have not in my 40 years of clinical practice whether that setting or in somebody that age who doesn’t have some underlying terrible neurological disease…it just doesn’t make clinical sense…”
Based on the RJN SIU findings and in order to stay in compliance with regulations, the case was formally filed with the Sonoma County District Attorney who subsequently determined that criminal charges were justified and filed against both the claimant as well as her sister. Since criminal charges filed in January of 2020, the claimant and her sister attended multiple criminal hearings and at one point underwent a “Fit for Trial” evaluation as the claimant’s attorneys argued that she did not have the mental capacity to stand trial. Multiple evaluations occurred and multiple doctors disagreed. In February, 2023 a criminal hearing occurred and at this time, both defendants made a motion for diversion under the new penal code section 1001.95 with an agreement to pay restitution of $17,000 over a one-year period of diversion. The court granted the motion. If they make those payments and do not pick up any additional charges or violations, the court will dismiss the matter.
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 4,000 examiners and the documented referrals by this unit have resulted in over 225 convictions for workers’ compensation insurance fraud in California. In just the last 4 years, we have secured $1,504,930.00 in court ordered restitution on behalf of our valued clients.
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