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 alleged workplace injury occurring on October 18, 2024, at the Bridgeport Library. The claim was submitted under the Self-Insured Schools of California (SISC) workers’ compensation program.

The claimant alleged she tripped on the reading-pit stairs while carrying books, resulting in reported injuries to her left arm, right ankle, and right foot. The incident was reported on October 21, 2024, and medical treatment was first sought on October 23, 2024. At that time, she 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.

Diagnostic imaging, including X-rays and MRIs, showed no acute fractures or significant structural injury. Only mild degenerative changes were noted in the left elbow. Despite the absence of objective traumatic findings, the claimant reported progressive symptoms and continued treatment.

Surveillance footage obtained from the Bridgeport Library did not depict any visible trip or fall at the reported location. The discrepancy between the claimant’s subjective complaints and the objective medical and video evidence, combined with the undisclosed prior motor vehicle accident, resulted in 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 Investigations’ Special Investigations Unit (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 criminal charges for workers’ compensation insurance fraud were filed against the claimant.

On February 12, 2026, during a pre-trial hearing, the claimant entered a guilty plea to the charged felony violations and paid full criminal restitution of $12,000.00.

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 Investigations significantly supported the criminal filing and successful resolution of the case.