One of our adjusters received a claim from a part-time hospital respiratory therapist of injuries to the shoulders from lifting patients. The claimant was paid lost wages for two years. The PQME gave the claimant a 10-pound lifting limit. In his deposition, the claimant testified that he could not, and had not, lifted more than… Read More
Major bodily injury claimed when car was going less than 2 mph?
Two years ago, an adjuster was assigned an auto injury claim involving one of our insured’s ambulances. Nothing like large commercial policy limits to whet an attorney’s appetite. Our driver admitted fault, actually offering to pay for the damage himself. It seems our ambulance caused a little damage – $530 worth – to the Prius…. Read More
Fraudulent durable medical equipment helped us break up a work comp ring
When Investigation Solutions started 13 years ago, we opened an investigation into Prime Orthopedics, noting what seemed to be unreasonably high charges for durable medical equipment (DME), billed on California workers’ compensation claims. DME must be prescribed by the attending physician. The actual equipment must be certified, and it must be billed with the appropriate… Read More
Here’s what happens when an “off-the-books” employee is injured
An Arrowhead General Insurance Agency premium auditor was working on a workers’ compensation policy audit for a construction company. The employer reported having only one employee. Their policy application showed a denial of the use of subcontractors. However, the premium auditor identified two claims filed during the policy year. The employer explained that they had… Read More
Worker claims injury after he quit
ACM’s claims examiner was assigned a two-month late report: a post-termination work injury claim. The attorney reported that the claimant fell from scaffolding, two stories off the ground, suffering major injuries. The insured said the claimant did not work on the claimed date of loss, nor did any of their staff, as they are closed… Read More
Insureds’ statements reveal fraudulent smoke and ash claims by PA firm
An adjuster was handling a smoke and ash claim in California, which was reported a year after the claimed wildfire. The inspection found ash in the home, with a cleaning estimate at $5,533.00. The claim was paid. The claim was made by a public adjusting (PA) firm, which stated the cost to clean the home… Read More