This case involves a fast-food employee who reported a slab of ice fell on her right arm. She was taken off work and treated for many months, yet continued to allege severe ongoing pain. Interestingly, the worker’s diagnostic imaging tests were normal, with no significant findings.
During one medical visit, her physician was unable to examine her arm/hand due to her hyper-sensitivity to touch and intolerable pain being greater than 10/10. After this exam, the ICW Group Nurse Case Manager and physician discussed the encounter. They agreed it appeared she was not forthcoming about the nature and extent of the alleged injuries, and it was agreed that a deeper investigation was warranted.
Surveillance doesn’t lie
Surveillance was immediately initiated, and the claimant was observed doing yard work and mowing the grass. She was able to use both hands to operate the lawn mower, lift and empty the grass-clipping bag, use a shovel, and move an outdoor metal table. She was not wearing a brace during surveillance and exhibited no difficulties ambulating.
ICW Group’s Special Investigations Unit (SIU) quickly shared the surveillance results with the worker’s physician. The doctor’s newly revised report indicated the worker was capable of working full duty and had reached what physicians call “Maximum Medical Improvement.” Further, the doctor reported that the worker had demonstrated she had not been forthcoming regarding her case. He discharged her due to noncompliance with the plan of care.
ICW Group referred the matter to the California Department of Insurance and the Shasta County District Attorney’s Office. Following a criminal investigation, the worker was charged with multiple felony violations. Ultimately, the worker was found guilty and ordered to pay more than $65,000 in restitution and court fines and serve probation.
Anti-fraud unit helps detect, deter, and defeat fraud
Learn how ICW Group’s coordinated approach between Triage Examiners, Claim Examiners, Nurse Case Managers, and SIU staff can support your workers’ compensation program. Visit our Policyholder Center for more information.
