Workers’ Compensation Insurance Fraud – Mono County, California

This matter involves a 53-year-old female employed as a Small Branch Coordinator with the Mono County Office of Education, who reported an October 18, 2024, alleged workplace injury when she reportedly tripped on the reading-pit stairs while carrying books, resulting in reported injuries to her left arm, right ankle, and right foot, at the Bridgeport Library. The claim was submitted under the Self-Insured Schools of California (SISC) workers’ compensation program.

The incident was reported on October 21, 2024, and medical treatment was first sought on October 23, 2024. At that time, the claimant was prescribed a wrist brace and ankle support and placed on work restrictions. Subsequent investigation revealed that the claimant was involved in a motor vehicle accident on October 2, 2024—prior to the alleged workplace incident—which she did not disclose in her workers’ compensation reporting or to her treating medical providers.

On-site security footage obtained by Apex Investigation Special Investigation Unit (SIU) from the Bridgeport Library did not depict any visible trip or fall at the reported time and location. Additionally, the discrepancy between the claimant’s reported mechanism of injury, her subjective complaints, objective medical evidence, and security video evidence, combined with the undisclosed prior motor-vehicle accident, led to the denial of the workers’ compensation claim on December 19, 2024.

Recognizing multiple indicators consistent with potential insurance fraud, the assigned claims examiner demonstrated diligence and sound investigative judgment by promptly referring the matter to Apex Investigation SIU for comprehensive analysis on January 28, 2025. Following completion of the SIU investigation, the evidence established a “reasonable belief” of suspected fraud, and the case was formally referred to the California Department of Insurance, Fraud Division, and the Mono County District Attorney’s Office in accordance with California Insurance Code §1871.4 and Penal Code §550(a)(1).

In April 2025, Apex SIU prepared and submitted a comprehensive documented referral to the Mono County District Attorney’s Office. On May 15, 2025, two felony charges for workers’ compensation insurance fraud were filed against the claimant in Mono County Superior Court. On February 12, 2026, during a pre-trial hearing, the claimant entered a guilty plea to two felony counts of California Insurance Code 1871.4(a)(1) and California Penal Code 550(a)(1) and paid full criminal restitution of $12,106,90.

Notably, the Mono County District Attorney’s Office does not receive dedicated grant funding for the prosecution of workers’ compensation fraud. The District Attorney’s Office advised that the thorough investigative documentation and presentation prepared by Apex Investigation SIU significantly supported the criminal filing and successful resolution of this case.