The RJN Special Investigative Unit was notified by the Riverside County District Attorney’s Office that they filed two felony counts against the claimant. In this case, the claimant was employed as a full-time County Maintenance Construction Worker. He alleged that while changing road signs, he tripped and landed on his right shoulder. During his 3-point contact, evaluations with PTP, and PQME, the claimant denied prior injury to the right shoulder. The PQME reviewed the claimant’s medical records of his prior right shoulder and recognized that the claimant had prior treatment right up until his current claim made against the insured. The RJN SIU investigation noted that the claimant’s denial of prior injuries affected the apportionment of his current claim. As such, a formal fraud referral was submitted, Subsequently, the Riverside County District Attorney charged the claimant with one count of (1871.4(a)(1) IC and one count of 550(b)(1) PC. After several criminal hearings, the claimant pled guilty and was ordered to pay $25,942.22 in restitution.
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 245 convictions for workers’ compensation insurance fraud in California. In just the last 4 years, we have secured $ 1,842,671.00 in court-ordered restitution on behalf of our valued clients.
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