Sunday, October 22, 2017


 

Celebrating 30 Years (1987 - 2017)

of Superior Service to our Valued Clients

 
   
Press Release

Restaurant Employee Charged With 14 Felony Counts of Insurance Fraud

10/9/2017

 On October 5th, 2017, the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Los Angeles County District Attorney’s Office regarding the filing of criminal charges based upon a documented SIU referral submitted.  In this case, the claimant worked as a chef and subsequently filed a continuous trauma injury via his Applicant Attorney.  As the claimant’s medical condition did not appear to be improving despite over a year and a half of medical treatment, a surveillance level investigation was authorized.  In the course of this surveillance investigation, evidence was obtained reflecting that the claimant was working at another restaurant while collecting TTD benefits.  The claimant’s deposition was subsequently secured and under the penalty of perjury, denied secondary employment or any other income.  The video evidence was then provided to the Panel QME, and in his supplemental report, it was critical in regard to the claimant’s overall credibility.  A documented referral was then submitted by the RJN SIU to the California Department of Insurance Fraud Division as well as to the Los Angeles County District Attorney’s Office.  After a thorough investigation, the claimant was formally charged with 14 felony counts in violation of Insurance Code Section 1871.4(a)(1), Penal Code Section 664(a); 118(a) and 550(b)(3.  The claimant’s preliminary hearing is scheduled for next month.

 

 

ABOUT R.J.N. SIU:

 

Formed in 1996, the SIU Division was created to assist California employers, small size 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 2,750 examiners and the documented referrals by this unit have resulted in over 165 convictions for workers’ compensation insurance fraud in California.  

 

Monterey County District Attorney’s Office Files Felony Fraud Charges

9/18/2017

 On September 13th, 2017, the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Monterey County District Attorney’s Office regarding the filing of a felony fraud charge based upon a documented referral. 

 

In this particular case, the claimant alleged to have injured her back while performing in home care duties for the assured.  Based in large part on subjective complaints, the claimant then began to receive temporary total disability payments.  During a telephone conversation with the examiner, the claimant hesitated when asked if she was working or receiving any additional income.  As such, a surveillance level investigation was authorized, and in the course of the surveillance, evidence was obtained indicating that the claimant was indeed working and not reporting that status to the examiner and/or the treating doctor.  Upon completion of the SIU level investigation, the case was then referred by the RJN SIU to the California Department of Insurance Fraud Division as well as to the Monterey County District Attorney’s Office.  Upon completion of a detailed criminal investigation performed by the Monterey County District Attorney’s Office, the claimant was formally charged with violation of Penal Code Section 550(b)(3) which is a felony.  At the criminal hearing held on this date, the claimant entered a not guilty plea.

 

ABOUT R.J.N. SIU:

 

Formed in 1996, the SIU Division was created to assist California employers, small size 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 2,750 examiners and the documented referrals by this unit have resulted in over 165 convictions for workers’ compensation insurance fraud in California. 

WCAB Judge Issues “Take Nothing” Order and Claimant Gets Charged With Insurance Fraud

9/6/2017

 On September 5th, 2017 the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Los Angeles County District Attorney’s Office regarding the filing of felony charges for workers’ compensation insurance fraud based upon submission of a documented referral.  This case involved a full time pest control exterminator who reportedly sustained a strain/sprain to his neck in February, 2014.  Medical treatment benefits were initially provided.  Subsequent evidence secured during an AOE/COE level investigation discovered that the incident never occurred.  A surveillance level investigation had established that the claimant had opened his own pest control business and was working without any restrictions.  In June, 2015, the claimant provided testimony in a WCAB trial revealing that he had not been truthful during his former deposition testimony.  On June 13th, 2016, the WCAB judge subsequently issued a “take nothing” based upon the evidence reviewed.  The case was then formally referred by the RJN SIU to the California Department of Insurance Fraud Division and to 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 664-118(a).  The claimant attended his preliminary criminal hearing on August 31st, 2017 and entered a not guilty plea.

 

ABOUT R.J.N. SIU:

 

Formed in 1996, the SIU Division was created to assist California employers, small size 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 2,750 examiners and the documented referrals by this unit have resulted in over 165 convictions for workers’ compensation insurance fraud in California. 

School Maintenance Worker Pleads Guilty

8/23/2017

 On August 23rd, 2017, the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the San Bernardino County District Attorney’s Office regarding the successful prosecution in the case of People of California vs. S. Aguilar.  In this case, the claimant filed a continuous trauma claim involving multiple body parts covering a timeframe of 2011 thru 2015.  As the claim progressed, red flag indicators were detected by the examiner.  As such, a surveillance level investigation was requested and video evidence was obtained of the claimant working out on several occasions at a gym.  While at the gym, he was videotaped bench pressing with dumbbells, lateral pull downs, bicep and triceps machines without any discomfort of apparent restrictions.  The claimant’s deposition was subsequently taken in San Bernardino County and in the course of his testimony, the claimant made material misrepresentations regarding this physical abilities under the penalty of perjury.  In accordance with the regulations set forth by the California Department of Insurance, the RJN SIU referred the case to their Fraud Division as well as to the San Bernardino County District Attorney’s Office.  Upon completion of their criminal investigation, the claimant was formally charged with four felony counts of insurance fraud and attempted perjury.  After attending several criminal hearings, the claimant agreed to enter into a plea bargaining agreement that entailed him providing the court with a cashier’s check in the amount of $5,994.45, as restitution to the School District.  As part of the plea bargain, the felony charges were then dropped and the claimant pled guilty to one misdemeanor count of insurance fraud in violation of 1871.4. 

 

ABOUT R.J.N. SIU:

 

Formed in 1996, the SIU Division was created to assist California employers, small size 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 2,750 examiners and the documented referrals by this unit have resulted in over 165 convictions for workers’ compensation insurance fraud in California. 

San Diego District Attorney’s Office Secures Conviction Based on Subrosa Video Evidence

8/16/2017

On August 8th, 2017, the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the San Diego County District Attorney’s Office regarding the successful prosecution in the case of People of California vs. J. Marquez.  In this case, the claimant alleged to have suffered a work related injury on a Friday, but did not report the injury and seek medical treatment until the following Monday.  Based in large part by his subjective complaints, the claimant was provided with work restrictions of no kneeling, squatting, no climbing, bending, twisting and no lifting over 25 lbs., stretch breaks for 5 minutes per hour, no forceful pushing or pulling more than 35 lbs.  As the employer was unable to accommodate, the claimant began to receive TTD benefits.  Based upon the initial red flag indicators, surveillance was performed by the RJN SIU Department.  In the course of the surveillance level investigation, the claimant was found to participate in an organized soccer club team over several dates, showing no sign of hesitation or restrictions. The claimant’s statement was promptly secured and he specifically denied being able to play soccer since his date of injury. The claimant made similar statements to his primary treating physician.  The video evidence was presented to the primary treating physician and in his supplemental report, he changed his medical opinion, releasing the claimant to work without restrictions and called into question the actual AOE/COE aspects of the injury.  The claimant also sent several e-mails to the examiner, asking for a quick settlement and he would stop pursuing the claim.  The case was then formally referred by the RJN SIU to the California Department of Insurance Fraud Division as well as to the San Diego County District Attorney’s Office.  Upon completion of their criminal investigation, the claimant was formally charged with 8 counts of insurance fraud in violation of Insurance Code Section 1871.4.  Given the impact of the subrosa video evidence, the claimant entered into a plea bargaining agreement in which he pled guilty to one count and agreed to pay restitution.  At the time of sentencing, the claimant provided his first installment for the restitution in the form of a cashier’s check made payable to the employer in the amount of $3,814.40.

 

ABOUT R.J.N. SIU:

 

 

Formed in 1996, the SIU Division was created to assist California employers, small size 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 2,750 examiners and the documented referrals by this unit have resulted in over 165 convictions for workers’ compensation insurance fraud in California.  

Claimant Pays $36,059.07 in Restitution to Her Employer as Part of Plea

8/7/2017

 On July 31st, 2017, the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Los Angeles County District Attorney’s Office regarding the successful prosecution in the case of People of California vs. S. Desselle.  In this case, the claimant alleged to have suffered a work related injury while working at a children’s center.  Based upon subjective complaints, she subsequently began to receive TTD benefits.  As the claim progressed, information came into the claim file indicating that the claimant may be working at a second job while collecting benefits.  The case was assigned to the RJN SIU for investigation.  Upon completion of that investigation, it was determined that the claimant had indeed secured secondary employment, working at a school district while at the same time, collecting TTD benefits.  The claimant never reported the secondary income to the examiner or her employer as required by law.  In compliance with the regulations set forth by the California Department of Insurance, the case was then submitted in a documented referral by the RJN SIU to that of the California Department of Insurance Fraud Division and Los Angeles County District Attorney’s Office.  The claimant was subsequently charged with violation of Insurance Code Section 1871.4 as well as violation of Penal Code Section 550(b)(3).  After attending only two hearings, the claimant agreed to enter into a plea bargain agreement that would entail her bringing in a cashier’s check to sentencing in the amount of $36,059.07 as restitution to the employer.  At the sentencing, aside from the restitution payment, the claimant was ordered to complete 200 hours of community service within six months and the felony charges on her record would be reduced to a misdemeanor. 

 

ABOUT R.J.N. SIU:

 

Formed in 1996, the SIU Division was created to assist California employers, small size 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 2,750 examiners and the documented referrals by this unit have resulted in over 165 convictions for workers’ compensation insurance fraud in California.  

Airline Employee Pays $28,000.00 in Restitution at His Sentencing

7/31/2017

 On July 24th, 2017, the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Los Angeles County District Attorney’s Office regarding the successful prosecution in the case of People of California vs. K. Song.  This claim involved an airline employee who was alleging an injury to his right foot, left lower back and left leg.  Based upon red flag indicators detected during the claims handling, the case was submitted to the RJN SIU Department.  Upon conducting a preliminary social network level investigation, it was determined that the claimant was involved in instructing martial arts mediation classes and that he was a Grand Master in Kung Fu.  Upon ascertaining that information, a surveillance level investigation was performed in which the claimant was found to be engaged in martial arts training from a standing position and moving about freely in his stances and techniques.  In his deposition, the claimant made several material misrepresentations made under the penalty of perjury.  Although admitting to being an instructor, the claimant stated that he was no longer able to physically instruct, but rather had to teach from a seating position.  He testified he would verbally tell the students what to do.  Once it was determined that the claimant had made no changes to his deposition transcript, the case was formally referred to the California Department of Insurance Fraud Division as well as to the Los Angeles County District Attorney’s Office.  Upon completion of their criminal investigation, the Los Angeles County District Attorney’s Office formally charged the claimant with one felony count in violation of Insurance Code Section 1871.4(a)(1).  After several hearings, the claimant agreed to enter into a plea bargaining agreement.  As such, on the date of his sentencing, he appeared with a cashier’s check made out to the airline in the amount of $28,000.00 for restitution.  The judge then sentenced him to three years formal probation and to perform 20 hours of community service. 

 

ABOUT R.J.N. SIU:

 

Formed in 1996, the SIU Division was created to assist California employers, small size 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 2,750 examiners and the documented referrals by this unit have resulted in over 160 convictions for workers’ compensation insurance fraud in California.  

Failing to Disclose Prior Injury Results in Criminal Charges

7/18/2017

 On July 17th, 2017, the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Los Angeles County District Attorney’s Office regarding the outcome of a preliminary hearing based upon a documented referral submitted.  In this case, within days after receiving a disciplinary action, the claimant filed a CT claim, alleging various body parts.  As the claim progressed, the examiner learned that the claimant had been involved in a motor vehicle accident prior to his workers’ compensation claim, where he injured the same body parts.  Further investigation revealed that the claimant received a settlement as a result of the injuries suffered in this motor vehicle accident.  The claimant failed to disclose the accident, pre-existing back and neck injuries to any of the treating doctors.  Moreover, he made material misrepresentations when he denied any such accidents or injuries in his deposition taken under the penalty of perjury.  Additional investigation also discovered that the claimant was working as an Uber driver during the timeframe he was receiving TTD benefits.  In compliance with the regulations set forth by the California Department of Insurance, this case was formally referred by the RJN SIU to their Fraud Division as well as to the Los Angeles County District Attorney’s Office Workers Compensation Fraud Unit.  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 664-118(a).  At the claimant’s preliminary hearing, he entered a not guilty plea.  The claimant was released on $50,000.00 bail pending his next criminal hearing.

 

 

ABOUT R.J.N. SIU:

 

Formed in 1996, the SIU Division was created to assist California employers, small size 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 2,750 examiners and the documented referrals by this unit have resulted in over 160 convictions for workers’ compensation insurance fraud in California.  

Surveillance at Knott’s Berry Farm Leads to Criminal Charges

7/12/2017

On July 12th, 2017, the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Los Angeles County District Attorney’s Office regarding the outcome of the preliminary hearing based upon submission of a documented referral.  In this particular case, the claimant worked as a line cook and was subsequently terminated for being a no show/no call for work.  He subsequently retained an attorney who filed an application alleging an injury to his back, legs, neck and both shoulders from unloading boxes of food.  A surveillance level investigation performed in advance of the claimant’s deposition found him going to Knott’s Berry Farm where he was videotaped going on several rides throughout the park.  In his deposition that was taken just one month afterwards, the claimant admitted going to Knott’s Berry Farm, but stated he did not go on any of the rides and utilized a scooter the entire time.  In the surveillance video, the claimant was never seen on a scooter.  The video evidence was the provided to the Panel QME for review and comment in a supplemental report.  In his report, the QME altered his original medical opinion and rated the claimant to have a zero whole person impairment.  Upon receipt of that report and in compliance with regulations set forth by the California Department of Insurance, the case was formally filed by the RJN SIU to their Fraud Division as well as to the Los Angeles County District Attorney’s Office.  upon completion of their criminal investigation, the claimant was subsequently charged with one felony count in violation of Insurance Code 1871.4(a)(2), one felony count in violation of Penal Code Section 550(b)(1) and one misdemeanor count in violation of Penal Code Section 664-118(a).  At the claimant’s preliminary hearing held on this date, he entered a plea of not guilty.  As such, he is now free on bail pending his next hearing. 

 

 

ABOUT R.J.N. SIU:

 

 

Formed in 1996, the SIU Division was created to assist California employers, small size 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 2,750 examiners and the documented referrals by this unit have resulted in over 160 convictions for workers’ compensation insurance fraud in California.

 

 

Claimant Ordered To Pay Back School District $18,720.00 in Restitution

6/22/2017

 On June 20th, 2017, the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Los Angeles County District Attorney’s Office regarding the successful prosecution in the case of People of California vs. S. Ashley.  In this particular case, the claimant was a Teacher Assistant who alleged that a student had bit her right index finger, resulting in an injury.  When the claimant showed her finger to her supervisor, the supervisor noted there was no blood, no broken skin and no discoloration of her finger.  Moreover, the claimant denied first aid treatment.  Four months later, she filed a workers’ compensation claim and during the course of the AOE/COE investigation, the claimant adamantly denied ever seeking any treatment in reference to her right index finger prior to the date of injury.  A subsequent medical canvass investigation revealed that just one week prior to the alleged date of injury, the claimant was treated at Centinella Hospital Medical Center Emergency Room for “right index finger pain/injury.”  During that examination, the claimant received three x-rays of the right hand and fingers and was prescribed 500 mg. of Vicodin.  Upon securing certified copies of the medical records along with the claimant’s recorded statement, the case was formally prepared and referred by the RJN SIU to that of the California Department of Insurance Fraud Division and to the Los Angeles County District Attorney’s Office.  The claimant was subsequently charged with one felony count in violation of Insurance Code Section 1871.4(a)(2) and one felony count in violation of Penal Code Section 550(b)(1).  After several hearings, the claimant entered into a plea bargaining agreement in which she agreed to plead no contest to Count #1 of Insurance Code Section 1871.(a)(2), as a felony.  She was placed on 3 years felony probation and required to complete 200 hours of community service.    In addition, she was ordered to pay restitution back to the School District in the amount of $18,720.00.

 

ABOUT R.J.N. SIU:

 

Formed in 1996, the SIU Division was created to assist California employers, small size 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 2,750 examiners and the documented referrals by this unit have resulted in over 160 convictions for workers’ compensation insurance fraud in California.  

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