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ARGUS WEST SIU CRIMINAL FILING

Plumber Claimant | Felony Insurance Fraud Charges Filed

Napa County, Calif., September, 2018 --- This case involves a 57-year-old male plumber who worked for the insured from August 2016 until approximately July 2017. The claimant filed a workers’ compensation claim for an injury to his back, which was sustained when he struck it against a slab of marble at a jobsite. Although he initially declined treatment, he later requested treatment, and the claim was reported to the carrier. Benefits were then initiated, since the insured did not dispute the claim.

After a period of no reported improvement, claimant consistently reporting highly subjective complaints, and the claimant’s failure to return to modified duty work that the insured was making available, Argus West was called in and a surveillance investigation was initiated. Surveillance conducted on multiple days in August and October of 2017 found the claimant engaging in contractor-type employment activities, including visiting numerous private residences where construction was taking place and wearing work attire while carrying and using various tools and equipment.

In direct contrast to surveillance, medical reporting reflected the claimant denied working, demonstrated significant limitations, and reported constant pain. In addition, during his December 6, 2017 deposition, the claimant testified he had not performed any work or employment activities for anyone since approximately June/July 2017.

Argus West SIU prepared a full Documented Referral Package to the Napa County District Attorney’s Office on January 22, 2018. Felony insurance fraud and perjury charges were filed on September 13, 2018 and the claimant’s arraignment is pending. The final restitution figure is pending conviction and is estimated at approximately $25,261.

Victoria Sparhawk


ARGUS WEST SIU CRIMINAL FILING

Hair Stylist Claimant | Felony Insurance Fraud Charges Filed

Los Angeles County, Calif., April 10, 2018 --- This case involves a 21-year-old female hair stylist, who is alleging a specific injury to her back.  The claim was accepted and TTD benefits were paid.

Throughout the course of her medical treatment, the claimant reported significant complaints of pain and injury, causing her treating physician to deem her Temporarily Totally Disabled. The claimant denied working activities to the QME and PTP.

Argus West surveillance and social media investigations revealed that the claimant was actually working for a new employer, doing the same type of work that she did for the insured.  Subpoenaed records from the subsequent employer found the claimant had filled out the new-hire paperwork the same day she resigned from the insured.  Despite this, the claimant continued to collect TTD benefits and report significant pain and limitations.

Argus West SIU prepared and submitted a full Documented Referral Package to the Los Angeles County DA’s Office on March 9, 2017.  Criminal charges were filed on April 10, 2018 and an arrest warrant is pending. The final restitution figure is pending conviction but is estimated to be upwards of $49,395.71.

Victoria Sparhawk


ARGUS WEST SIU CRIMINAL FILING

Sewing Machine Operator  | Felony Insurance Fraud Charges Filed

Los Angeles County, Calif., April 11, 2018 --- This case involves a 44-year-old female Sewing Machine Operator, who is alleging a cumulative trauma injury to her back, shoulder, knee, ankle, hand, hips, and other multiple body parts, and also stress. The claim was denied.

Throughout the course of her medical treatment, the Claimant reported significant complaints of pain and injury, causing her treating physician to deem her Temporarily Totally Disabled.

Argus West Surveillance found the claimant to be active and engaging in employment activities, doing work similar to what she did for the insured.  Subpoenaed records and further investigation confirmed suspicions that the claimant was engaging in employment activities, which overlapped the period of EDD-SDI benefits she was receiving. Throughout the course of the claim, the claimant consistently denied engaging in employment activities prior to being released from care. She further denied prior injuries and treatment to the same body parts, despite repeated questioning regarding that issue from treating physicians and the QME.   The claimant testified at four depositions, changing her story each time. Ultimately, the QME found the Claimant lacked credibility and found no periods of disability and no need for future medical care.

Argus West SIU prepared and submitted a full Documented Referral Package to the Los Angeles County DA’s Office on May 3, 2017.  Criminal charges were filed on April 11, 2018 and an arrest warrant is pending. The final restitution figure is pending conviction, but is estimated to be upwards of $90,000.00.

Victoria Sparhawk


ARGUS WEST SIU CRIMINAL FILING

Maintenance Worker | Felony Insurance Fraud Charges Filed

Los Angeles County, Calif., January 3, 2018 --- This case involves a 48-year-old male maintenance worker who filed a workers’ compensation claim alleging a specific right knee injury sustained as a result of carrying a dresser down some stairs while working. The claim was immediately reported and benefits initiated.

After a period of time, with no indication of improvement, fairly significant ongoing subjective complaints, and a tip from the insured suggesting the claimant might be working as a contractor, Argus West was called in to initiate a surveillance investigation. Surveillance conducted over the course of several days found the claimant engaging in physical activities inconsistent with medical reporting. The claimant was exceeding restrictions and also performing work as a painter. He was found repeatedly traveling to a private residence where he used tools, went up and down ladders, and painted exterior fixtures.

In direct contrast to the surveillance evidence, the claimant told the insured he was in too much pain to return to work. He told his medical providers he had significant symptoms and was not working. He also told the field investigator who interviewed him that he had not performed any work of any type since his injury.

Argus West SIU prepared a full Documented Referral Package to the Los Angeles County District Attorney’s Office on January 3, 2018. Felony insurance fraud charges were filed on September 7, 2018 and the claimant’s arraignment is pending. The final restitution figure is pending conviction but estimated at approximately $21,982.

Victoria Sparhawk


ARGUS WEST SIU - CRIMINAL FILING

Farm Laborer Felony Charges Filed

Tulare County, Calif., February 13, 2018 --- This claim involves a 53-year-old male Farm Laborer who was first hired by the insured on April 14, 2014. In the late morning of May 13, 2016, the Farm Laborer sustained significant injuries to his face, including contusions, lacerations and a nasal fracture. He was transported by ambulance to the hospital where he was admitted and remained for six days before his release.

Argus West, Inc. was called to investigate the case and found there were some variations and inconsistencies in the exact description that the Farm Laborer told the insured and all initial medical providers. He said that his injuries were sustained as a result of tripping and falling while walking in the orchard at work. In direct contrast, interviews with other workers and witnesses revealed that the Farm Laborer had been drinking the morning of the injury incident and was antagonizing another worker, which resulted in a physical altercation with the other worker.

The claim was denied on June 9, 2016. To date, the Farm Laborer has not litigated or contested the denial. Although no benefits were provided, the treating hospital filed a lien against the carrier for approximately $45K and, additionally, there are investigation costs and legal costs as a direct result of the misrepresentations made by the Farm Laborer.

Argus West SIU prepared and submitted a full Documented Referral Package to Tulare County District Attorney’s Office on November 21, 2016. Criminal charges were filed on February 13, 2018 and an arrest warrant is pending. The final restitution figure is pending conviction and is estimated to be approximately $4700. More significantly, the charges will provide a valid defense to contest paying the $45K hospital lien.

Victoria Sparhawk


CA DIR Medical Fraud Prevention Heats Up

The top lien filers are responsible for roughly 75% of all lien claims filed. Many of these individuals filing liens are either being prosecuted for or had already plead guilty to fraud.

The state enacted two new laws addressing this lien problem. On January 1, 2017, SB 1160 and AB1244 became law. SB 1160 requires the CA DIR to automatically stay all liens owned by providers indicted or charged with a crime. Also, AB 1244 requires the AD to suspend any provider from participating in workers' compensation once they have been convicted of fraud.

The current list of providers whose liens are automatically stayed at the current time can be found at:

http://www.dir.ca.gov/fraud_prevention/

Our Provider Fraud Task Force Team is currently working on many of these high profile cases.


California bucks trend as workers comp claims increase

Employment Practices Workers Comp Coverage Claims Management Workers Comp Pricing California workers compensation claim frequency increased 3% from 2010 to 2014 despite an 11% fall in claim frequency in most other states during that time, according to the California Workers' Compensation Insurance Rating Bureau.

In a report released Thursday, Oakland, California-based WCIRB compared its comp claim frequency data with claim frequency in 35 states and the District of Columbia, where the National Council on Compensation Insurance Inc. acts as the workers comp ratemaker.

WCIRB said in the report that California workers have shifted toward more hazardous industries, such as construction and manufacturing, as those sectors have increased hiring in recent years.

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California Has Highest Claim Frequency in Nation

Sacramento, CA (WorkersCompensation.com) - In the latest update to the Analysis of Changes in Indemnity Claim Frequency report, WCIRB researchers find that indemnity claim frequency increased in California by 3% from 2010 to 2014 while frequency for National Council on Compensation Insurance (NCCI) states declined by 11% over the same period. The WCIRB report reflects insurer unit statistical and aggregate financial call data submitted to the WCIRB through the third quarter of 2015, as well as other external data, in order to identify the key factors driving these recent frequency increases.

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Workers' compensation executive pleads guilty in federal court

A former El Dorado Hills man has pleaded guilty in federal court to using business funds for personal expenses. Gregory J. Chmielewski, 46, of West Bend, Wisc., operated a business in Roseville and later Sacramento called Management Resources Group California LLC, which also went by the name Independent Management Resources. The company was supposed to sell and manage workers' compensation insurance for companies, eventually paying money for valid claims. But Chmielewski spent funds that were supposed to be reserved for claims, and the company couldn’t cover claims. On Friday he pleaded guilty in Sacramento to two counts of mail fraud for transferring business funds to his own personal use. According to the plea agreement, California workers' compensation insurance rates rose quickly in early 2003. Some entrepreneurs negotiated agreements with California Indian tribes to collaborate on business ventures to sell alternative insurance plans not subject to the state's insurance regulations because the ventures operated under the sovereign domestic nation status of the tribe. That’s what Chmielewski did.

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Southern California Family Arrested in $24M Fraudulent Workers’ Comp Billing Scheme

California Department of Insurance detectives arrested nine individuals involved in a complex scheme allegedly targeting more than 230 workers’ compensation insurers and self-insured employers. Siblings Francisco Javier Gomez, Jr. and Angela Rehmann, owners of G&G Interpreting Services, allegedly fraudulently billed more than $24.6 million for interpreting services for injured workers with Latino surnames.

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California Construction Company Owner Nabbed for Workers’ Comp Fraud

The owner of a Northern California construction firm was arrested Thursday on nine felony counts of workers’ compensation insurance fraud and tax evasion totaling $187,707 in losses. William Huffman, 47, of Sacramento, owner of Capitol City Contractors, allegedly underreported $755,899 in payroll to avoid paying workers’ comp premiums for dozens of employees.

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