PRESS RELEASE – CLAIMANT (CONVICTION)

This case centers on a 45-year-old male employee of a county water department who filed a workers’ compensation claim on March 1, 2024, alleging injuries to his neck and lower back sustained in a minor motor vehicle accident while on duty. Following his report, the claimant was diagnosed with sprain and strain injuries and was placed on total temporary disability, with work restrictions that included limited standing, walking, bending, and lifting. The claimant continued to report significant pain and functional limitations, including difficulty performing basic daily activities.

In July 2024, the insured received credible information suggesting the claimant was actively operating a plumbing business while receiving total temporary disability benefits. Apex Investigative Services was retained to conduct a background investigation and surveillance. The investigation revealed that the claimant had registered a plumbing business as a corporation with the California Secretary of State just two weeks prior to filing his workers’ compensation claim. Surveillance conducted in July and August 2024 captured the claimant performing physical labor inconsistent with his reported disability. Activities included repeatedly lifting and carrying heavy items, climbing into a truck bed, dragging boxed toilets, and handling tools and equipment—all without any visible signs of pain or physical limitation.

On September 12, 2024, an Apex SIU Investigator compiled and submitted a detailed video reference guide and footage to the treating physician. Upon review of the footage, the physician expressed concern about the claimant’s reported limitations and subsequently provided a written report to the claims examiner on October 17, 2024, indicating the claimant had not been truthful during medical evaluations.

Based on the investigation, the matter was referred to the California Department of Insurance Fraud Division and the Sacramento County District Attorney’s Office. A criminal investigation followed, and on November 15, 2024, the District Attorney’s Office filed a felony charge of workers’ compensation insurance fraud against the claimant. The claimant was arraigned and held to answer. During a mandatory criminal settlement conference on February 4, 2025, the claimant pled guilty to a misdemeanor violation of Insurance Code § 1871.4(a)(1). At the time of the plea, the claimant provided full restitution in the amount of $43,752.86 via a certified bank check.

This case was successfully prosecuted by the Sacramento County District Attorney’s Office, Workers’ Compensation Fraud Unit, and underscores the ongoing collaboration between SIU departments and local and state agencies to combat insurance fraud in efforts to reduce the cost of workers’ compensation insurance and claim payouts for employers.