Workers Compensation Insurance Fraud in California

 

“The Serial claimant”

Syzmon Nowak, age 50, was a cook at a famous San Diego diner.  After complaining to his boss about a leaky refrigerator, he subsequently slipped and fell on the wet floor, hurting his back.  Several people witnessed his fall.  He filed his work comp claim with my organization and his claim was quickly accepted.  It was a simple “soft tissue” back injury, but Syzmon’s subjective complaints of severe pain convinced his primary treating physician to keep him on Total Temporary Disability for several months after he should have been back to work.

The assigned claims adjuster alerted SIU to a red flag.  Syzman’s co-workers told the AOECOE investigator that Syzmon had been calling them to about a high quality dog food he was selling. Syzmon  even disclosed to his doctor that he had sold “a few bags” of dog food since his injury, but that he had not made more than a few dollars on it.  I investigated the dog food business, even calling the owner of the dog food company, but I couldn’t get any proof that Syzmon was selling dog food in any great quantities.  

I still felt there was more to investigate.  Syzmon’s injury was very minor.  There were no abnormal findings on X rays and MRIs.  Yet, he always said his pain was “9 out of 10, or worse”.  I noted in his medical reports that he disclosed only one prior back injury from a workers comp claim five years prior.  Otherwise, he stated, more than once, he had no other prior back injuries or insurance claims.

The claims adjuster and I searched ISO claim search for Syzmon Nowak and we found one workers comp back injury, five years prior to the current.  Just out of curiosity, we subpoenaed the claims file fr0m the other insurer.  When it arrived, we were surprised to see that Syzmon’s earlier claim was very similar to the current one.  He had been working as a cook, he complained to the manager about a leaky refrigerator and subsequently slipped on the wet floor, hurting his back in front of several witnesses.  

Also, in the prior claim, there was a mention of an even earlier back injury clam with yet another carrier.  I realized that ISO Claim search records only went back seven years and this third injury was nine years ago.  I called the adjuster contact on that earliest claim and heard a familiar story—Syzmon worked as a cook, he warned the manager about a leaky refrigerator, and subsequently slipped on the wet floor in front of three witnesses. 

To me, it looked like Syzmon had a habit of filing back injury claims, with identical facts.  The amazing thing was that he did actually fall on his back three times in front of witnesses.  He was committed to this scheme. 

I shared this info with Claims and Legal and they set Syzmon’s depo.  Syzmon recounted the accident at our insured.  Our attorney asked him about the injury five years ago, and Syzmon admitted to it, although he did not describe it happening the way it appeared in the subpoenaed records.  Finally, Syzmon denied any other back injuries or filing any other workers comp claims.

After the depo, we subpoenaed the records from the earliest claim.  We provided a copy of both prior injury files to Syzmon’s primary treating physician along with the depo transcript wherein Syzmon failed to disclose the earliest claim.  The physician was struck by the similarity of the three slip and fall injuries and he discharged Syzmon from care with no need for future medical or permanent disability. He also opined that Syzmon was never really TTD. 

I submitted my suspected fraud referral to the DA s office.  The key evidence was the depo transcript, the prior medical records and the final report from the current physician.  The DA filed multiple counts of felony insurance fraud against Syzmon.  Syzmon’s claimed that having immigrated from Poland thirty years earlier, he was not fluent in English.  Although he had never requested an interpreter for his medical appointments or in his deposition, he now insisted he needed a Polish language interpreter for the Superior Court hearings.  Such interpreters are not easy to find so several hearings had to be postponed.

During the investigation, I spoke with Syzmon and found he spoke English fluently.

However, the Criminal case went forward as a Bench Trial (no jury was present, only the judge). Syzmon was found guilty on all counts.  He was sentenced to one month in County Jail, three years probation, restitution and he had to agree to get his workers comp case dismissed with prejudice.

Syzmon later appealed the criminal conviction.  The higher court affirmed the lower courts ruling.

Hopefully,  Syzmon has found employment outside the restaurant industry.