This case involves the Claimant, a 39-year-old Certified Nurse Assistant, who filed a workers’ compensation claim on May 23, 2017. The Claimant alleged injuries to her forearms, wrists, and right shoulder as a result of assisting a patient who became combatant while removing his surgical dressings. The patient squeezed and twisted the Claimant’s right arm, and she believed she hit her forearms on the bedrails. The Claimant sought medical treatment for her injuries and was placed on modified duty, as she alleged that her regular duty work caused her pain. However, she refused to accept modified duty. During the claims process, it was revealed through interviews with her co-workers that the Claimant was trying to work part-time because she was going to school, but there were no part-time positions. Her supervisor noted that the Claimant asked about going part-time in April 2017. Co-workers noted that the Claimant said that if she could not work part-time, she would take a leave of absence. The modified duty conflicted with the Claimant’s school schedule, as they were simultaneously.

Surveillance was conducted on the Claimant, which revealed her to be physically active. She would frequent a UFC gym where she would perform exercises such as lifting dumbbells in an exercise class. The Claimant testified in a deposition stating that because of the pain, she was unable to lift or grasp with her right hand. She denied lifting anything over five pounds since she was injured. She denied that she could lift a gallon of milk but stated she could lift her purse and a loaf of bread. The Claimant noted that she still went to the gym but only utilized the treadmill and sauna. She denied that she participated in any classes since June 2017 due to her injuries. This was contradictory to what the surveillance video showed.

The SIU investigation revealed the Claimant was suspected of falsely overexaggerating her physical limitations and underexaggerating her physical capabilities to obtain workers’ compensation benefits to which she was not entitled. Additionally, the Claimant made several material misrepresentations throughout the claims process and during deposition testimony. On October 4, 2018, a fraud referral was submitted to the Los Angeles County District Attorney’s Office and the California Department of Insurance. On October 16, 2018, the Los Angeles County District Attorney’s Office notified APEX that they would open a criminal investigation due to our fraud referral. Subsequently, a documented fraud referral was provided to the Los Angeles County District Attorney’s Office pursuant to the 1877 demand letter.

On April 9, 2020, the Claimant was criminally charged with two (2) felony counts of workers’ compensation fraud and attempted perjury. The Claimant was arraigned and pleaded not guilty to both counts. During a preliminary court hearing on January 13, 2021, the Claimant withdrew her plea of not guilty and pleaded no contest. The court found the Claimant guilty of workers’ compensation fraud and accepted the plea, and the time for sentencing was waived. The Claimant was to complete 100 hours of community service. There was no restitution ordered in this case due to the Claimant being injured on the job and that she was placed off work by her medical provider.

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