This case involves the Claimant, a 56-year-old female Firefighter who filed a workers’ compensation claim on January 18, 2016. The Claimant alleged injuries to her lower back, bilateral lower extremities, and bilateral feet because of cumulative trauma from conducting her regular job duties. The Claimant sought medical treatment for her injury and was taken off work and placed on Temporary Total Disability benefits (TTD). During the claims process, the Claimant attempted to be forthcoming with her concurrent employment but did not reveal all her concurrent employment or supplemental income.

The Claimant was suspected of working for multiple concurrent employers while collecting TTD disability benefits and omitting them to treating physicians, the claims examiner, and an investigator to obtain workers’ compensation benefits to which she was not entitled. An SIU investigation was conducted that revealed the Claimant acknowledged that she knew it was fraudulent to work while being off work on TTD. She was also told by the claim’s adjuster on multiple occasions, both verbally and in writing, that she could not participate in volunteer or employment-related work while being off work on TTD. Despite knowing this, she proceeded to engage in work-related activities to earn additional money while simultaneously collecting TTD benefits while being off work for her injuries. When she was directly asked about her employment by an investigator, she intentionally gave a false history.

On September 28, 2017, a fraud referral was submitted to the San Mateo County District Attorney’s Office and the California Department of Insurance. On October 10, 2017, the San Mateo County District Attorney’s Office notified us that they would open a criminal investigation due to our fraud referral. Subsequently, a Documented Fraud Referral and a copy of the claim file were provided to the San Mateo County District Attorney’s Office pursuant to the 1877 Demand Letter.

From 2018 to 2022, Apex SIU Investigators worked closely with the San Mateo County District Attorney’s Office investigators and prosecutors and provided additional information to assist them with their investigation. In February of 2020, the Claimant was criminally charged with (10) felony counts of workers’ compensation fraud and grand theft. Subsequently, a warrant was issued for the Claimant’s arrest. In May of 2022, a plea agreement was reached with the Claimant, which resulted in a conviction with restitution being imposed:

• Pled to (1) misdemeanor count of insurance fraud under PC 550(b)(3).
• Restitution to be paid to the City of San Bruno in the amount of $49,457.00.
• Miscellaneous fines of $200.00.
• 90 days county jail.
• 1-year probation.
• Agreement to waive any future medical and not to apply for IDR (Industrial Disability
  Retirement).

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