Monday, June 17, 2019


 

Celebrating Over 30 Years (1987 - 2019)

of Superior Service to our Valued Clients

 
   
Press Release

Instructional Aide Arrested at School Site

6/17/2019

 The Special Investigative Unit of RJN Investigations, Inc. was notified by the San Bernardino County District Attorney’s Office in regard to the arraignment of a school district’s instructional aide based upon a documented referral.  In this particular case, the examiner detected significant red flag indicators and as such, authorized a surveillance level investigation.  In the course of the surveillance investigation performed by the RJN SIU, over 2 hours of video evidence was obtained depicting the claimant performing a wide variety of outside physical activities, showing no restrictions or utilization of artificial support.  In her subsequent Panel Qualified Medical Evaluation, the doctor wrote the following:

 

“As I indicated, due to the applicant’s subjective complaints of pain and her unwillingness to provide maximum effort on examination, her apparent limitations and range of motions are invalid…”

 

The video evidence was then provided to the PQME for review and comment in a supplemental report.  The QME then made significant changes to his initial medical opinion and concluded the following in his report:

 

“I do not see that a re-evaluation of this patient would serve any specific purpose…”

 

 

In accordance with the regulation set forth by the California Department of Insurance, the case was then formally referred to their Fraud Division as well as to the San Bernardino County District Attorney’s Office District Office.  Upon completion of a criminal investigation by the District Attorney’s Office, the claimant was charged with a felony in violation of Insurance Code Section 1871.4(a).  The claimant was then arrested at her work site.  At her arraignment on May 29th, 2019, 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 190 convictions for workers’ compensation insurance fraud in California.

School Custodian Pleads Guilty to Insurance Fraud

6/3/2019

 The Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Ventura County District Attorney’s Office in regard to the successful prosecution of a custodian employed by the Simi-Valley Unified School District. In this particular case, the claimant alleges to have sustained injuries to his right shoulder while pulling trash bags out of the cans. The claimant sought medical treatment and subsequently filed his claim. During initial treatment, the claimant admitted to owning and operating his own personal business. A Surveillance investigation was quickly authorized, and RJN Investigations obtained video of the claimant lifting furniture, pushing heavy machinery and working. When questioned, the claimant indicated to investigators that his business was still in operation, however because of his injuries, he was no longer doing any of the work himself, rather his family was completing his jobs. Surveillance was provided to his medical doctor, who in turn changed his medical opinion of the claimant returning him back to work with no restrictions. The RJN SIU formally referred the case to the Ventura County District Attorney’s Office as well as the California Department of Insurance Fraud Division. Upon completion of their criminal investigation, the claimant was formally charged and entered a not guilty Plea during his arraignment. During his most recent court date, the claimant accepted a plea deal in which he changed his not guilty plea to Guilty of count 1 Insurance Code 1871.4(a). As part of his plea deal, Count 2 will be dismissed. The claimant was ordered to pay restitution in the amount of $24,000.00 which has already been turned over by the claimant. The claimant is scheduled to be formally sentenced on 06/19/2019 when it is expected his felony guilty plea will be reduced to a misdemeanor as part of his plea agreement.      

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 190 convictions for workers’ compensation insurance fraud in California.

Playing Soccer While on Workers Compensation Leads to Criminal Conviction

5/28/2019

 The Special Investigation Unit of RJN Investigations was notified by the Ventura County District Attorney’s Office as to the successful prosecution in the case of the people of California Vs. J. Garcia. In this case, the claimant was alleging to have suffered from injuries to multiple body parts throughout the course of his employment. The examiner detected several initial red flag indicators and as such, authorized a surveillance level investigation. The surveillance investigation found the claimant to be extremely active which included competing in soccer leagues while showing no signs of hesitation or discomfort. When he was questioned during his deposition taken within Ventura County, the claimant was specifically asked if he still played soccer. The claimant stated that he had not played soccer for over a year. Furthermore, he indicated that he stopped playing soccer while he was still employed. The RJN SIU formally referred the case to the Ventura County District Attorney’s Office as well as the California Department of Insurance Fraud Division. Upon completion of their criminal investigation, the claimant was formally charged and entered a not guilty plea during his arraignment. At his most recent court appearance, the claimant accepted a plea deal in which he changed his not guilty plea to guilty of count 1 Insurance Code 1871.4(a). As part of his plea deal, count 2 will be dismissed and the claimant will be sentenced to 5 years of formal probation. The claimant is scheduled to be formally sentenced on 06/12/2019 at which time a restitution figure will be assigned by the Judge.     

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 190 convictions for workers’ compensation insurance fraud in California.

Claimant Accepts a Plea Deal After Admitting Guilt. Must Pay Restitution and Complete Community Service

5/16/2019

 On May 16th, 2019 the Special Investigative Unit of RJN Investigations was formally notified by the Los Angeles County District Attorney’s Office pertaining to the successful prosecution in the case of the people of the State of California Vs. R. Tovar. In this case, the claimant was employed as a Caregiver for the Department of Social Services. The claimant was assigned to her client and was terminated on her second day of assignment by the client and only worked a total of 3 hours. After being terminated, the claimant continued to submit timecards alleging she was working for the client for another 470 hours between June 1st, 2016 through October 15th, 2016. Furthermore, it was determined based on a review of the RJN SIU that the claimant was also forging her client’s signatures on the timesheets. Based RJN SIU’s referral to the Los Angeles County District Attorneys Office, a criminal investigator was assigned to conduct an interview of the claimant. During this interview, the claimant admitted to falsifying her timesheets as well as filing the false Workers Compensation Injury claim alleging to have sustained a cumulative trauma injury to her back, neck and nervous systems/psyche due to work duties through 10/31/16. Because admission to guilt does not eliminate a criminal filing, the claimant was subsequently charged with 3 counts of 1871.4(A)(1), 487(B)(3) {Grand Theft} and 470(D){Forgery}. After multiple court dates and continuances, the claimant agreed to a plea deal in which she has until April 28th, 2020 to pay restitution in the amount of $6,300.71 and complete 200 hours of community service. Should she not make her regular agreed upon payments to IHSS her felony charge will not be reduced to a misdemeanor and other fines/penalties may be enforced. 

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 185 convictions for workers’ compensation insurance fraud in California.

Operators of Vocational Rehabilitation School Are Charged With 37 Felony Counts

4/29/2019

 On April 24th, 2019, the Special Investigative Unit of RJN Investigations, Inc. was notified in regard to the arraignment of the operators of the vocational school entitled “GDS Institute.”  In this case, the primary treating physician informed the claims examiner that the claimant had admitted to him that she never attended the vocational rehabilitation school that charged the claim file.  In addition, she was told by the school that if anybody asked, she was to say that she attended the program, which was supposed to be comprised of 28 weeks of training.  The claimant also stated that although she did not attend any training, the school supplied her with a certificate of completion and a computer they said was valued at $4,000.00.  The rehabilitation school in turn submitted billing in the amount of $9,926.00 to the claim file.  In the course of the SIU level investigation performed by RJN Investigations, additional claim files were identified.  The RJN SIU then formally referred the case to the Los Angeles County District Attorney’s Office as well as to the Department of Insurance Fraud Division.  As the investigation intensified, the Orange County District Attorney’s Office assisted in the investigation.  Upon completion of the joint task force investigation, the two operators were each charged by the Orange County District’s Attorney’s Office with 37 felony counts, including insurance fraud and conspiracy to commit insurance fraud.  If convicted, each defendant faces a maximum sentence of 41 years in State Prison.  After their arrest, they were released on $100,000.00 bail for each.  At the hearing on April 24th, 2019, both 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 187 convictions for workers’ compensation insurance fraud in California.

Monterey County District Attorney’s Office Secures Conviction of Claimant For both Workers Compensation Insurance and Welfare Fraud

4/16/2019

 The RJN Investigation’s Special Investigative Unit was recently informed by the Monterey County District Attorney’s Office as to the successful prosecution in the case of the People of California v. E. Hernandez. In this particular case, the claimant alleged to have injured her back while performing in-home care duties for the insured.  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 and receiving any additional income.  As a result, the examiner proactively assigned the case to the RJN SIU to conduct a surveillance level investigation.  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 treating doctor.  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 Workers’ Compensation Fraud Unit.  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.  During the criminal investigation, it was also determined that the claimant failed to report her second job to the Department of Social Services. By failing to disclose the second job to both the insurer and the Department of Social Services, she obtained income and benefits that she was not entitled to.  As such, she was also charged with a felony violation of the Welfare Institution Code Section 10980(c)(2). On March 27th, 2019 Judge Panetta sentenced the claimant to 180 days in county jail will then be placed on 3 years formal probation.  She was also ordered to pay back the employer for the workers compensation insurance fraud $ 18,369.00 in restitution. 

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 187 convictions for workers’ compensation insurance fraud in California.

City Maintenance Worker Charged with Two Felony Counts of Insurance Fraud

4/8/2019

 

On April 2nd, 2019, the Special Investigative Unit of RJN Investigations was notified by the Los Angeles County District Attorney‘s office as to the filing of criminal charges based upon a documented referral submitted to their office. In this case the claimant alleged to have suffered a work-related injury as a result of a chemical getting into an eye while operating a paint sprayer. After almost a year of receiving medical treatment and not being able to return to work, the claim examiner assigned the case to the RJN SIU for surveillance in advance of his upcoming deposition in Los Angeles County to determine his true outside activity level.  During the surveillance level investigation substantial video evidence was obtained depicting the claimant performing construction related duties at his side business, showing no restrictions and utilizing power tools. At his deposition taken a month later he denied any type of secondary employment, work or income, and moreover that he could not safety operate the same power tools that the video surveillance showed him to be using. The case was then filed with the California Department of Insurance Fraud Division as well as to Los Angeles County District Attorney‘s Office Workers Compensation Fraud Unit. Upon completion of their criminal investigation the claimant was formally charged with two felony counts in violation of Insurance Code Section 1871.4(A) as well as attempted perjury in violation of Penal Code section 664/118(a). As a result, a felony arrest warrant was issued with bail set at $30,000.00.

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 187 convictions for workers’ compensation insurance fraud in California.

San Diego County District Attorney’s Office Files Charges on Bus Driver

3/25/2019

On March 21st, 2019, the Special Investigative Unit of RJN Investigations was notified of charges being filed as a result of a documented referral. In this case, the claimant was employed as a Bus Driver for the San Diego USD. The claimant alleged an injury to his lower back, which was accepted. The claimant was evaluated and placed on TTD. The claimant had PT, epidural, chiropractic and meds but never improved. He remained on TTD based on how he presents to his doctors. Surveillance of the claimant’s activities find him active. The claimant's most active times were when he was surveilled coaching football at a high school. He was observed standing, walking, bending, twisting and performing all his coaching activities with no sign of pain or artificial support, hesitation or reluctance. All of this is in stark contrast to how he presented during medical examinations who have kept the claimant on TTD since his injury. The claimant further advised that he had significant difficulty just performing his daily activities. Based RJN SIU’s referral to the San Diego County District Attorney’s Office, a criminal investigator was assigned to the case and conducted interviews with RJN Surveillance Investigators. After the completion of their investigation, RJN SIU was formally advised that the claimant was charged with 8 counts. Counts 1 and 2 were 1871 (a)(2).  Counts 3 through 7 were 1871 (a)(1) and Count 8 was PC 550 (b)(3).  The claimant was issued a court notice and is scheduled to be arraigned on 04/16/19.

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 187 convictions for workers’ compensation insurance fraud in California.

Forgery of Timesheets Lead to Criminal Charges

3/4/2019

On February 26th, 2019 the Special Investigative Unit of RJN Investigations was notified of charges being filed as a result of a documented referral. In this case, the claimant was employed for a Caregiver for the Department of Social Services. The claimant was assigned to her client and was terminated on her second day of assignment by the client and only worked a total of 3 hours. After being terminated, the claimant continued to submit timecards alleging she was working for the client for another 470 hours between June 1st, 2016 through October 15th, 2016. Furthermore, it was determine based on a review of the RJN SIU that the claimant was also forging her client’s signatures on the timesheets. Based RJN SIU’s referral to the Los Angeles County District Attorneys Office, a criminal investigator was assigned to conduct an interview of the claimant. During this interview, the claimant admitted to falsifying her timesheets as well as filing the false Workers Compensation Injury claim alleging to have sustained a cumulative trauma injury to her back, neck and nervous systems/psyche due to work duties through 10/31/16. Because admission to guilt does not eliminate a criminal filing, the claimant was subsequently charged with 3 counts of 1871.4(A)(1), 487(B)(3) {Grand Theft} and 470(D){Forgery}. A warrant was issued, and the claimant turned herself into the authorities and is scheduled to be arraigned on March 14th, 2019 where she will formally enter a 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 187 convictions for workers’ compensation insurance fraud in California.

Custodian Arrested and Charged in Ventura County

2/14/2019

 On February 14th, 2019 the Special Investigative Unit of RJN Investigations, Inc. was formally notified by the Ventura County District Attorney’s Office in regard to the arrest and arraignment of a custodian employed by the Simi-Valley Unified School District. In this particular case, the claimant alleges to have sustained injuries to his right shoulder while pulling trash bags out of the cans. The claimant sought medical treatment and subsequently filed his claim. During initial treatment, the claimant admitted to owning and operating his own personal business. A Surveillance investigation was quickly authorized, and RJN Investigations obtained video of the claimant lifting furniture, pushing heavy machinery and working. When questioned, the claimant indicated to investigators that his business was still in operation, however because of his injuries, he was no longer doing any of the work himself, rather his family was completing his jobs. Surveillance was provided to his medical doctor, who in turn changed his medical opinion of the claimant returning him back to work with no restrictions. Based on this fact and in compliance with the regulations set forth by the California Department of Insurance, our office provided the Ventura County District Attorney and Insurance Fraud Division with our investigative findings in a documented referral format.  On January 22nd, 2019, the claimant was arrested at his place of employment by the Ventura County Sheriff’s department.  He was formally advised of his 2 Felony charges of 550(a) PC and 1871.4(a)(1) IC.  On February 14th, 2019 the claimant was arraigned in Ventura County Superior Court.

 

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 187 convictions for workers’ compensation insurance fraud in California.

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