In this particular case, the claimant was alleging, “that he pulled and lifted a heavy subject from the ground,” injuring his low back. At the time of the injury, the claimant was employed as a full-time police officer with the City of Indio. As the restrictions listed by the primary treating physician could not be accommodated by the assured, the claimant began to receive TTD benefits. As the claimant did not appear to be getting any better despite providing medical treatment, the proactive adjuster from the CJPIA Athens account authorized RJN to perform surveillance. In the course of the surveillance level investigation, the claimant was found to be active at a Cross-Fit Gym, as well as operating a backhoe at a private residence. Extensive video was obtained of the claimant performing activities in contradiction to his listed restrictions. The video evidence was subsequently forwarded to the QME, who made significant changes in his medical opinion based upon review of the subrosa video evidence. In compliance with the regulations set forth by the California Department of Insurance, as well as the San Bernadino County District Attorney’s Office, the case was formally filed by the RJN SIU. Upon completion of a criminal investigation by the San Bernardino County District Attorney’s Office, the claimant was formally charged with felony workers’ compensation insurance fraud in which he subsequently pled not guilty. The claimant’s next criminal hearing is scheduled for next month.
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 250 convictions for workers’ compensation insurance fraud in California. In just the last four years, we have secured $1,989,784.00 in court ordered restitution/savings on behalf of our valued clients.
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