Workers Compensation Insurance Fraud in California

 The Total Fakers---

In my experience, the rarest Claimant fraud scenario is the one where the person completely fabricated a workplace injury.  Usually, the worker experienced some kind of injury and exaggerates the incident to get more workers comp benefits than they are entitled---usually staying off work longer than they need to.

The following two workers comp claimants stick out in my mind as “total fakers”.   Ted Wilson was working his second day on the job as a Grounds man for a tree trimming company.  Ted and his co-worker Randy were feeding debris into the big woodchipper machine.  Somehow, a long rope with a small hook on the end was mixed in with the debris.  When the rope entered the chipper, the end with the hook came whipping rapidly into the machine.  On its way in, Randy was stuck on the side of his torso by the hook and he fell to the ground in pain.  Ted also fell to the ground alongside Randy.  Ted was holding his head and shouting “I’ve been hit, I’ve been hit”.   The supervisor noted that Ted was making a bigger fuss than Randy, who had obviously suffered a severe injury.

The supervisor helped Randy and Ted off the ground.  He saw that Randy was bleeding from his side and in great pain.  Ted, however, did not seem to have a scratch on him, but he claimed his head was “killing him”.  The supervisor called an ambulance for Randy and was a little exasperated when Ted insisted on being transported for emergency medical care, too.

A claims adjuster named Tricia was assigned to handle both of the resulting workers comp claims.  Tricia immediately accepted Randy’s claim.  Due to the rope injury, the doctors removed Randy’s spleen and he was hospitalized for over a week.   Tricia put Ted’s claim on Delay in Decision (for 90 days) so that it could be investigated before it was accepted.  She contacted the Special Investigation Unit and I was assigned to the case.

To start my investigation, I spoke to the supervisor who was there at the time of the incident.  He said he did not believe Ted had really been injured.  He said it did not make sense to him because Randy had obviously been struck by the rope but Ted was standing at least six feet away.  The supervisor said he did not see any blood or obvious wound on Ted’s head.

 Next, I called the ER doctor who treated Ted when he was brought in by ambulance.  I noted the doctor had diagnosed Ted with a “contusion” to his head.  I asked the doctor if he had actually seen a contusion, and he said, “I did not really see anything, but the patient said he got hit in the head, so I wrote “contusion”.

Meanwhile, Ted obtained an attorney to represent him in the claim.  The attorney had Ted see a Qualified Medical Evaluator (QME).  Based on his exam of Ted, this MD diagnosed Ted with a head injury which was causing Ted to experience sever migraine headaches.  The MD said the injury was related to the rope incident.   Ted told the QME doctor he had never had migraine headaches prior to the incident.

Tricia, the adjuster, conferred with our Legal Department over whether the claim should be accepted, based on the QME’s medical report.  Our defense attorney recommended we depose Ted before we accept the claim.  We held Ted’s deposition a month before the 90 day deadline to accept or deny the case.

Ted revealed some interesting information  during the deposition-- Ted held a Masters Degree in Engineering.  Our attorney asked Ted why he had gotten a job doing landscaping for minimum wage when he had an advanced degree in the sciences.  Ted said he was new to the area and just needed some work until he found something in his chosen field.

Our attorney had Ted describe the facts of the incident step by step.  She also asked him about his ongoing symptoms—the severe migraine headaches.  Ted emphatically stated he had never had migraine headaches prior to the incident with the rope and woodchipper. 

After the deposition, Tricia was under pressure to make a decision on accepting or denying the claim.  On the one hand, the QME medical report said the injury was industrial.  On the other hand, the mechanism of the injury did not seem credible.

Tricia noted that Ted had mentioned seeing one local medical doctor prior to the incident.  She subpoenaed the doctor’s records.  The doctor’s records showed that he had seen Ted 3 weeks before the incident.  The doctor prescribed Ted medical marijuana.  The doctor listed the reason for the prescription as “chronic migraine headaches”.

Therefore, Ted lied in his deposition when he said he had never had migraines before the chipper incident.

Tricia had very little time before the 90 deadline.  We delivered the marijuana doctor’s report to Ted’s QME and asked him to write a supplemental report.  In the new report, the QME stated the injury was non-industrial and Tricia was able to deny the claim on the 89^th day.

I referred Ted’s case to the local District Attorney’s office and the Department of Insurance Fraud Unit.  The DA’s office filed Felony insurance fraud charges against Ted.  He entered a guilty plea.

On the day of his sentencing, Ted was accompanied by members of his church who had raised $2000 for Ted to give as a “down payment” on the restitution he owed our insurance company.  The judge sentenced to 4 years of formal probation (instead of prison) because of the down payment.  The judge also ordered Ted to pay the remainder of his restitution ($8000) in monthly payments.

In the hallway outside the courtroom smiled at me and told me, “Don’t worry, I forgive you” while surrounded by the supported church members.

After the sentencing, Ted never made any restitution payments.  I found he had left the state and moved back east, violating his probation.  Unfortunately, the amount of his restitution was not enough to justify extraditing him back to California.  I doubt he ever re-paid the good hearted church members who helped him out.

My personal feeling about the case is that Ted intentionally caused the accident by putting the rope in the chipper.  I think he probably got the job with intent to fake the injury and file a workers comp claim.

If he did not cause the accident, he at least tried to take advantage of a situation where his co-worker, Randy, did suffer a severe injury.

In the end, we could not prove that he faked the injury.  But we did prove that he lied in his depo and to the QME doctor about his history of migraines, and that was good enough to get the conviction.   Even though he violated his probation by leaving the state and failing to pay his restitution, we avoided liability for a fraudulent workers comp claim, which would have negatively impacted our insured, the tree trimming company.  And if Ted ever returned to California, there is an arrest warrant waiting for him.

Here's a quick story about another “total faker”.  One of my fellow SIU investigators handled this one, and I think he did a great job with it.

Bob Wilson worked as an armed security guard.  He was assigned to the night shift.  He was given a company car which he used when driving to various locations he was assigned to guard at night.

Bob worked nights alone.  One morning, he reported an incident to his boss--- he had been the victim of a drive by shooting.  He said somebody had shot at him with a handgun, hitting the passenger side door of his vehicle.  At the time, Bob was parked in the parking lot of a strip mall he was assigned to guard that night.  He said when he heard the shots fired, he ducked down in the car. 

Bob told his boss he was not hit by the bullets but he wrenched his back while trying to avoid the gunfire.  Bob’s boss called the local police to investigate the shooting.  He also filed a workers comp claim for Bob who said he was in severe pain.

While getting treatment for his back pain, Bob maintained his story.  There were stories in the local media about the brave security guard who survived a drive by shooting.

During the Sheriff’s investigation, they examined Bob’s vehicle.  They removed the bullets from the passenger side door and did a ballistics test.

They found all the bullets had come from Bob’s own gun.

When the Sheriff’s Department interrogated Bob and confronted him with the evidence, he admitted he had shot his own car and concocted the story about the drive by.  He admitted he was hoping to get some time off work and to get paid for the workers comp claim.

The DA filed charges against Bob related to filing a false police report and insurance fraud.  Bob entered   a guilty plea to all the charges.  He was sentenced to a year in state prison.  When he got out, he paid his restitution payments to our insurance company.