Work Comp Fraud: Painted into a corner

The claimant suffered a low back injury when he fell off a ladder while performing his job duties as a painter. The initial injury was found compensable. The claimant had minimal objective findings that did not support his subjective complaints. Surveillance was conducted on two days between March and May. The surveillance showed the claimant operating a tow truck and pushing a car across the street. He was bending, stooping, squatting and moving with no hesitation. The case was assigned to ISI’s Special Investigations Unit. We obtained a recorded statement from the claimant in May, where he alleged he could not lay down flat or perform any duties required as a painter and had denied working since the date of injury.

All the investigative evidence obtained was presented to the current treating physician, the prior treating physician and the PQME. All doctors agreed that the claimant was permanent and stationary as of the March video surveillance and returned to work at full duty. Total Temporary Disability (TTD) benefits had been paid through mid-June, causing a TTD overpayment of $3,599. They found that medical treatment requested was no longer appropriate and that the claimant’s misrepresentations caused a delay in declaring him permanent and stationary. The San Diego District Attorney demanded the claims file and has filed six counts of 1871.4 (a) (1).

The claimant plead guilty to one count of LC1871.4(a)(1). Restitution was ordered in the amount of $25,374. The DDA called and advised we have received three $1,000 cashier checks. As a result of the investigation conducted by Investigation Solutions, Inc., there was an estimated cost savings of $125,558 to our client.