This case involves the claimant, a 34-year-old male custodian, who is suspected of filing a fraudulent workers’ compensation claim. It is believed the claimant was malingering and over-exaggerating the symptoms of his injury to obtain workers’ compensation benefits to which he was not entitled. The claimant alleged that he sustained a right shoulder injury while working for the insured on April 19, 2022.

The claimant reported to his treating physician that he could not move his shoulder. However, surveillance revealed the claimant being physically active while driving, riding a bicycle, getting airborne on a bike, using both arms/shoulders to carry a wooden bicycle jump ramp, bending at the waist, taking pictures, carrying a camera, and carrying a tripod. The claimant showed no apparent signs or characteristics of being severely injured. The claimant provided a recorded statement stating that he spent his time icing or placing heat on his right shoulder and purchased a brace he wore daily. However, surveillance footage showed otherwise.

A doctor video showing was conducted where the doctor confirmed the claimant could perform the observed tasks without issues and changed his medical opinion, indicating the claimant could work full duty. The doctor did not feel the claimant was truthful about his physical capabilities or limitations and that the claimant exaggerated the extent of his condition during medical visits to continue receiving benefits and time off work. The doctor noted that if he had seen the video footage before placing the
claimant on his work status, he would not have imposed any physical restrictions. The doctor deemed the claimant’s injuries as nonindustrial, and the claimant was released to full work duty with no permanent impairment.

On May 27, 2022, a fraud referral was submitted to the California Department of Insurance and the Solano County District Attorney’s Office. Due to our fraud referral, an 1877 Demand Letter was received from the Solano County District Attorney’s Office. The letter indicated their agency would open a criminal investigation in which they requested a copy of the entire claim. A copy of the claim file and Documented Fraud Referral were later sent to their office.

Throughout 2022 and 2023, Apex SIU Investigators worked closely with the Solano County District Attorney’s Office and provided additional information to assist with their investigation. On August 4, 2023, the claimant was criminally charged with 10 felony counts of workers’ compensation fraud by the Solano County District Attorney’s Office. In December 2023, the claimant pled to three misdemeanor counts of workers’ compensation fraud, where restitution was imposed in the amount of $17,392.04, with an immediate payment of $6,000.00.

This case was successfully prosecuted by the Solano County District Attorney’s Office, Workers’ Compensation Fraud Unit.