This case involves the claimant, a 46-year-old female Custodial Worker, who filed a workers’ compensation claim on June 11, 2020. The Claimant alleged that she sustained a right foot/ankle injury while working for the insured when a coworker fell on top of her while they were cleaning together. The claimant sought medical treatment and was diagnosed with a contusion to the right foot. She was taken off work and placed on total temporary disability. In July 2020, she allegedly began to experience pain in her lower back due to the injury. The claimant remained off work, collecting total temporary disability benefits while continuing to seek medical treatment for her injury. During numerous medical visits, the claimant presented herself to treating physicians, and her condition worsened. She had constant severe pain and had to use a cane to walk. She would be tearful, cry, and sob in the exam room, as well as present herself as being in so much pain she was hunched over in a stooping position. The claimant could not walk heel to toe and had difficulty bending, squatting, and walking.

In June 2021, a nurse case manager accompanied the claimant at her medical appointments and noted the claimant’s symptoms were unfounded, and tests of her lumbar spine and lower leg pain were unremarkable. During this same time, Apex obtained a surveillance video of the claimant, revealing her to be physically active, contradicting how she presented herself to treating physicians. The Claimant was seen working on cars. Specifically, she was seen sanding a vehicle, utilizing a power sander, a sand block, or a handgrip tool, attaching or detaching auto parts with both hands, and relocating detached auto parts without assistance. She was seen going to the laundromat, pushing carts around full of clothes, and carrying bags of clothes. The claimant did not utilize a cane or walking device during the surveillance. She walked in what appeared to be a normal manner. The claimant did not display the characteristics of someone injured at such a severe level as she presented to treating physicians.

In July 2021, after obtaining surveillance video, Apex obtained a recorded statement from the claimant where she made several material misrepresentations regarding her physical limitations from her injury to the interview. She stated she needed to use a cane beginning in July 2020, right after her injury. She had to hold on to furniture to assist her in walking through her home, and she was required to hold on to the handrails when utilizing the stairs. She was unable to lift over 10 or 15 pounds and had not tried since the date of her injury. During the interview, the claimant denied being able to lift groceries or push a shopping cart. She denied being able to do her laundry at the laundromat, as she could not lift a basket with clothing. She denied being able to squat, bend, bend forward, run, or work on vehicles, as depicted in the surveillance video.

After obtaining the above evidence, Apex SIU Department was assigned to prepare a documented fraud referral and presented the case to the California Department of Insurance Fraud Division and the Los Angeles County District Attorney’s Office. As a result of the referral, the Los Angeles District Attorney’s Office conducted a criminal investigation into the matter. On July 18, 2023, the Los Angeles County District

Attorney’s Office filed a criminal case against the claimant for two felony counts of workers’ compensation insurance fraud.

On September 11, 2024, the claimant appeared at her preliminary hearing. The first felony count was dismissed, and the claimant entered a plea of no contest to the second felony count, charging her with workers’ compensation insurance fraud for lying to her doctor. The claimant’s sentencing was continued for 18 months to evaluate whether the claimant would pay restitution for $9,999.00 and complete 100 hours of community service. If she completes these terms, the claimant’s charge will be reduced from a felony to a misdemeanor. If she fails to do so, she will be sentenced on the felony plea, and she will be sentenced to felony jail time.

The Los Angeles County District Attorney’s Office’s Workers’ Compensation Fraud Unit successfully prosecuted this case.