“The Exaggerator”
Bill Simms was a 37 year old warehouse worker who filed an
injury claim after a forklift operator ran over his foot, spraining his
ankle. His clam was accepted and he was
placed on TTD status by his primary treater.
Simms was given a Cam Walker boot to keep his ankle stabilized while he
recovered.
After several treatments, the physical therapist noted in
his report that Simm’s legs were tan, suggesting that he was frequently outside
without the cam walker boot. However,
Simm’s told the PT that he “always” wore the boot, except when sleeping or
taking a shower. The claims adjuster
recognized the red flag and contacted SIU.
I worked with the adjuster and we assigned sub-rosa, using an outside PI
vendor. The plan was to conduct
surveillance of Simms before, during and after his next PT visit.
On the morning of the PT appointment, the PI vendor captured
video of Simms washing his truck in the parking lot of his apartment
building. Simms was dressed in shorts
and flip flops and he was not wearing the walker boot. His movements seemed normal. When Simms left home for his PT appointment,
he was wearing the walker boot and he now had a crutch.
The PI vendor parked near Simms in the PT’s parking
lot. The PI captured video of Simms
walking very slowly into the PT office, using the crutch, and still wearing the
boot. During the appointment, Simms reiterated that he “always” wore the cam
walker boot and could not walk anywhere without it. After the appointment. Simms walked out of
the office, very slowly. However, once
he reached his truck, the video showed him taking off the cam walker boot and
throwing it into the back of his truck, along with the crutch.
The PI followed Simms to a gas station, where Simms filled
up his truck with gas, wearing flips flops and walking very differently than he
just had at the PT’s office. When we
showed the video to Simms’s primary treater, he noted that Simm’s
“demonstrative behavior” in using the crutch and boot was strikingly different
from his demeanor before and after the PT appointment.
Based on the video, the primary treater released Simms from
care, with no permanent disability or need for future medical care. The district attorney filed felony fraud
charges against Simms based on the concept that Simms’s demonstrative behavior
was a material misrepresentation that had enabled him to gain benefits that he was
not entitle to.
Simms entered a guilty plea and received three years
probation and an order to pay restitution to the insurer.
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