2017 CASBO Conference Workers Compensation Fraud

Transcription

1 April 14 th, CASBO Conference Workers Compensation Fraud Robert J. Nagle President RJN Investigations, Inc. Pamela Leitao Deputy District Attorney Orange County

2 Workers Compensation Fraud The process starts with the detection of red flag indicators.

3 Workers Compensation Fraud 1. Injured worker is disgruntled, seeming to retire, or facing imminent firing or layoff. 2. Accident occurs late Friday afternoon or shortly after the employee reports to work on Monday. 3. Accident is not witnessed. 4. Fellow workers hear rumors circulating that the accident was not legitimate. 5. Accident occurs in an area where injured employee would not normally be. 6. After injury, injured worker is never home or spouse/relative answers phone saying injured worker just stepped out or is in the shower, etc. 7. Injured worker changes physician when release for work has been issued. 8. Injured worker has a history of reporting subjective injuries. 9. Several employees from same employer have similar injuries and use same doctors and/or attorneys. 10. First notice of claim comes from attorney or medical clinic.

4 Workers Compensation Fraud 11. First notice of injury or claim made after employee is terminated or laid off. 12. Employee cancels or fails to keep appointment or refuses a diagnostic procedure to confirm an injury. 13. Attorney is known for handling suspicious claims. 14. Physician is known for handling suspect claims. 15. Boiler plate medical reports are identical to other reports from same doctor. 16. Diagnosis inconsistent with medical treatment. 17. Injuries are all subjective (i.e. pain, headaches, nausea, inability to sleep) and there are no credible objective findings. 18. Surveillance or tip indicates the totally disabled worker is currently employed elsewhere. 19. Claimant overly familiar with the workers compensation system and terminology. (continued) 20. Background investigation reveals evidence of self-employment, prior claims, motor vehicle accident and/or domestic violence issues.

5 Workers Compensation Fraud The SIU is then notified from either the examiner, employer, coworker or informant. If the investigation identifies evidence of suspected insurance fraud, they will then move to file the case. Once notified, the SIU will conduct a timely initial investigation and develop an SIU action plan.

6 Workers Compensation Fraud Cases can be referred in either a Preliminary FD-1, or documented referral format. By law, the case must be referred to both the District Attorney s Office of venue and to the California Department of Insurance Fraud Division. A completed FD-1 averages 3 pages and can be submitted electronically.

7 Workers Compensation Fraud Suspected Fraudulent Claim (SFC) Referral Form (FD-1)

8 Workers Compensation Fraud A documented referral would include the FD-1, along with: SIU summary report SIU timeline Master copy of the subrosa video evidence

9 Workers Compensation Fraud Copies of any recorded statements. Certified copy of any depositions. Copy of all the medical reports.

10 Workers Compensation Fraud Copy of the claim file. Copy of the current financials. Copies of any investigative reports. The document referral is then provided to the Department of Insurance Fraud Division and County District Attorney s Office in person, meeting or ideally hand-delivered.

11 JUSTICE IS BLIND Why am I telling you this and showing you this image?

12 What do you need to give me? Just the facts, ma am

13 PROOF BEYOND A REASONABLE DOUBT Hyperbole Magnification Exaggeration Bias Belief without hard evidence Conclusions not supported by the facts (admissible evidence)

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16 HOW DO YOU GET THE DA INTERESTED IN YOUR CASE? It starts with the FD-1 and your documented case referral 1) Fact based 2) When was the crime committed? 3) Where was the crime committed? 4) How was it committed? 5) Who is the witness to the crime? 6) Why? 7) What is the materiality? 8) Be organized 9) Know your case 10) Be responsive 11) To whom

17 County Employee Sentenced To 109 Days In Jail And Ordered To Pay $14, In Restitution Date: 7/26/2016 On July 26 th, 2016, the Special Investigative Unit of RJN Investigations, Inc. was notified regarding the successful prosecution by the Ventura County District Attorney s Office in the case of People of California vs. L. Boggess. This case involved a claimant who was employed by the Ventura County Human Service Agency, who filed a workers compensation claim back in March, 2007, indicating paralyzing pain. She subsequently received medical treatment and temporary disability payments until November, 2011, when she was cleared to return to work without restrictions. Shortly thereafter, the claimant provided new work restrictions from a separate doctor which limited her to lifting no more than 5 lbs. The surveillance unit of RJN Investigations conducted surveillance which resulted in video evidence of the claimant lifting car tires mounted on wheels, each weighing 45 lbs., and carrying them for a distance of approximately 50 feet. In her deposition secured after the video evidence was obtained, the claimant testified that she was unable to lift and move anything heavier than a gallon of milk. Upon completion of the documented referral, the case was submitted to the California Department of Insurance Fraud Division as well as to the Ventura County District Attorney s Office. Upon completion of a detailed criminal investigation, the claimant was formally charged with four felony counts of workers compensation insurance fraud. After attending over 25 hearings, the case then went to a jury trial. After deliberation, the jury came back with a verdict of guilty on each and every count. On July 26 th, 2016, the claimant was formally sentenced to 109 days in jail, 60 months formal probation as well as ordered to pay restitution made payable to the County of Ventura in the amount of $ 14,

18 County Employee Sentenced To 109 Days In Jail And Ordered To Pay $14, In Restitution

19 Benching Over 315 Lbs. Helps Lead To Insurance Conviction Date: 5/13/2016 On May 13 th, 2016, the Special Investigative Unit of RJN Investigations, Inc. was notified by the Orange County District Attorney s Office in regard to their successful prosecution in the case of People of California vs. M. Tafua. This case involved an Orange County Social Service Agency Group Counselor. He alleged that back on January 8 th, 2014; he injured his right shoulder and elbow, restraining someone while working at the Orangewood Children s Home. The agency attempted to accommodate his injury by assigning him to modified duties with work restrictions provided by the treating physician. The claimant subsequently went to the doctor and claimed he was unable to use his right arm. As a result, the agency could not accommodate that restriction and the claimant was placed on Temporary Total Disability. The case was then assigned to the RJN SIU Surveillance Unit. In the course of that surveillance, video evidence was obtained of the claimant performing various outside physical activities, including working out at a gym, bench pressing over 315 lbs. The claimant was subsequently questioned and denied violating any of the work restrictions provided by the treating doctor. In accordance with the requirements set forth by the California Department of Insurance Fraud Division, the case was then formally referred by the RJN SIU to their department as well as to the Orange County District Attorney s Office Workers Compensation Fraud Unit. A joint criminal investigation resulted in the District Attorney s Office formally charging the claimant with two felony counts in violation of Insurance Code Section (a)(1) and two felony counts of Penal Code Section 550(b)(3). On May 13 th, 2016, the claimant entered into a plea bargaining agreement in which he agreed to plead guilty to misdemeanor insurance fraud. In exchange, he was sentenced to three years informal probation, ordered to complete 100 hours of community service and provide restitution in the form of a cashier s check at the time of sentencing in the amount of $30, The cashier s check was provided to the court on the date of sentencing addressed to the County of Orange.

20 Benching Over 315 Lbs. Helps Lead To Insurance Conviction

21 Orange County Risk Management Secures Another Arrest Date: 6/23/2016 On June 23 rd, 2016, the Special Investigative Unit of RJN Investigations, Inc. was notified by the Orange County District Attorney s Office regarding the arraignment that took place on this date based upon a documented referral. In this case, the claimant was actually doing community service on behalf of the County as part of the sentencing for a prior DUI conviction. While being transported to a worksite, the County vehicle was involved in a minor motor vehicle accident. As a result, the claimant alleged to have suffered various injuries including the loss of hearing. A surveillance level investigation performed by the RJN SIU Department found that the claimant utilized a walker while attending his medical and legal appointments. However, at no other time in the course of multiple hours of surveillance video was the claimant observed utilizing a walker. He was actually videotaped operating a bicycle and a motor vehicle despite having his license formally revoked. He was also videotaped engaging in day labor work activities. At his deposition, the claimant made significant material misrepresentations made under the penalty of perjury. The case was then formally referred to the California Department of Insurance Fraud Division as well as to the Orange County District Attorney s Office. Upon completion of an in depth criminal investigation by the Orange County District Attorney s Office, the claimant was formally charged and arrested for felony workers compensation insurance fraud. At his arraignment on this date, the claimant entered a not guilty plea. The County intends to seek restitution on this case in the amount of $55,

22 Orange County Risk Management Secures Another Arrest

23 Former Sheriff Deputy Convicted For Committing Insurance Fraud Date: 3/1/2017 On March 1 st, 2017, the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Orange County District Attorney s Office regarding the successful prosecution in the case of People of California vs. N. Zappas. In this particular case, while working as a Sheriff Deputy in the Harbor Patrol Division, the claimant tripped over a firehose and fell on his back, injuring his left shoulder, left side of his neck and lower back. He was placed on work restrictions of no heavy lifting, pushing or pulling greater than 10 lbs. by the treating physician. The Orange County Risk Management Department subsequently received an anonymous tip indicating that the claimant was engaged in cross-fit type activity involving heavy lifting. A surveillance level investigation performed by the RJN SIU secured several hours of video evidence of the claimant engaged in consistent cross-fit activities which included lifting over 200 lbs. In December, 2015, while under oath during his deposition, the claimant denied lifting anything over 20 lbs. since the date of injury and claimed he could not lift anything heavy, could not do squats and could not run. The video was then shown to the doctor who changed his medical opinion. In compliance with regulations set forth by the California Department of Insurance, a documented referral was then submitted to the Orange County District Attorney s Office and to the California Department of Insurance Fraud Division. Upon completion of an extensive criminal investigation, the claimant was formally charged with 11 counts of insurance fraud and 7 felony counts of perjury under oath. Given the extent of the evidence, the claimant subsequently entered into a plea bargain agreement. After pleading guilty to committing insurance fraud, the claimant was subsequently sentenced to 3 years formal probation, 180 days in jail and ordered to pay $34, in restitution to that of the County of Orange. In addition, he was also required to dismiss his 2011 and 2015 workers compensation claims with prejudice as a condition of his probation.

24 Former Sheriff Deputy Convicted For Committing Insurance Fraud

25 SIU Investigations Teamwork Teamwork = Successful SIU Prosecution