The Special Investigative Unit of RJN Investigations, Inc has learned of the successful prosecution in the case of People of California v J. Shalmoni based on a documented fraud referral submitted.
In this case, the claimant worked as an assistant cook for a senior healthcare center. The claimant alleged an injury to the left groin after carrying a large bucket of water. During his first visit with the industrial physician, the claimant denied a second job and denied performing strenuous activities outside of work. The days following his injury and initial evaluation, surveillance was conducted which showed the claimant cooking and catering for a party in a private home on one day and catering for another party at another private home on another day. He was seen carrying cooking equipment, food, coolers, prepping a fryer, bending at the waist and lifting items, and he was seen hanging from a swing like device at a children’s playground. Subsequently, the claimant followed up with his primary treating physician, to which he reported new symptoms of left knee pain which became more pronounced over the weekend, and he reported an electrical sensation associated with neck pain that radiated down his right lower extremity. His claim was accepted for left groin and knee pain only. As he followed up with his primary treating physician, the claimant denied a second job and he repeatedly denied bending or lifting materials. He stated he could not lift his daughter that was 30 lbs. due to pain and reported staying at home.
The surveillance video evidence was then reviewed by the claimant’s primary treating physician who concluded the claimant was not being truthful about his pain level and his ability to work. The primary treating physician returned the claimant to full duty and discharged the claimant from care.
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 the Fraud Division as well as with the Los Angeles County District Attorney’s Office. Upon completion of their criminal investigation, the claimant was formally charged with one felony count in violation of Insurance Code Section 1871.4(a)(1) and one felony count in violation of Penal Code Section 550(a)(1). After attending several criminal hearings, the claimant agreed to plead guilty as part of a plea bargain agreement. The claimant was then sentenced to one year summary probation, 30 days of community service and ordered to pay $ 16,374.40 in restitution to his employer.
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 $1,596,117.00 in court ordered restitution on behalf of our valued clients.
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