A 47-year-old repairman sustained a head injury when a hammer fell on him. He didn’t seek medical treatment for more than a week and filed a workers’ comp claim for multiple additional injuries that were disputed.
He attended two Qualified Medical Examinations (QMEs) and a neurology exam while walking with a cane. He reported significant pain and difficulties with daily activities, including driving and riding in a car. The psychiatric QME noted he had a very unusual combination of responses that are associated with non-credible reporting of somatic and cognitive symptoms as well as memory complaints.
The ICW Group Claims Examiner questioned the injuries and level of disability, so surveillance was dispatched by our Special Investigations Unit (SIU). In the video obtained during surveillance, the repairman appeared much more able-bodied than he reported to his doctors. He was seen walking in a normal manner without a cane, bending at the waist, entering and exiting his vehicle fluidly, and driving on several occasions, including one trip of more than 140 miles.
Due to what appeared to be a misrepresentation of symptoms, SIU referred the case to the Department of Insurance and Orange County District Attorney for investigation. The misrepresentations are material to the claim because the payment of undue benefits and medical treatment ultimately results in increased costs to ICW Group’s policyholder.
