The Special Investigative Unit of RJN Investigations, Inc. was recently notified by the Los Angeles County District Attorney’s Office of their successful prosecution in the case of People of California v M. Lopez based upon a documented fraud referral. In this case, the claimant was employed as a caretaker of the California Department of Social Services – I.H.S.S. At the time of the claimant’s deposition, he appeared wearing a back support and ambulating with the aid of a cane. Proactively, the Senior Claims Examiner authorized the RJN SIU Department to perform RUSH surveillance. During the ongoing surveillance, extensive video evidence was obtained depicting the claimant ambulating freely without any noticeable signs of artificial support or noticeable restrictions. The video evidence was subsequently provided to the QME for review and comment. In his QME report, it stated in part the following:
“Overall, review of the subrosa video footage demonstrates a degree of inconsistency between what Mr. Lopez reported and exhibited at the time of the PQME examination, and what he was visualized performing during the video segments…My reporting on this case has changed as a result of this additional information and my revised reporting follows below…”
In compliance with the regulations set forth by the California Department of Insurance Fraud Division, the RJN SIU formally filed this case with their office as well as with the Los Angeles County District Attorney’s Office. Felony charges were then issued against the claimant, and a preliminary criminal hearing was set. The claimant failed to appear for the hearing and as a result, a felony bench warrant was issued for his arrest. The claimant subsequently had formal interactions with law enforcement and their check of NCIC revealed his felony warrant where he was promptly arrested. After several criminal hearings, the claimant entered into a plea bargain agreement entailing formal probation and having to pay restitution in the amount of $ 43,263.00.
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 260 convictions for workers’ compensation insurance fraud in California. In just the last four years, we have secured $ 2,215,290.00 in court-ordered restitution on behalf of our valued clients.
Leave a comment!