History of Injuries Revealed, Criminal Charges Follow

A 56-year-old education assistant claimed to injure her elbow while pulling a gate open at work. Some five months later, this California woman claimed to aggravate the injury to her elbow, at which time she first filed a workers’ compensation claim.

When ICW Group’s Claims Examiner contacted the injured worker, she avoided any questions about her injury history, ultimately opting to retain legal representation. 

ICW Group initiated a deeper investigation into the claim for a few reasons:

  • It was an unwitnessed injury incident;
  • The injury was reported on delay; and
  • There was clear hesitancy by the worker to discuss whether the elbow was previously injured.

This investigation revealed that this woman had sought medical treatment for her elbow about five months prior to when she claims to have injured it at work. 

At the time of her deposition, this worker denied any problems with her elbow before the alleged incident at work. Further, when specifically asked whether she had ever been seen at the medical facility ICW Group’s investigation discovered, she denied ever doing so. 

Pre-existing conditions and workers’ comp

An aggravation of a pre-existing injury condition may be compensable under a workers’ compensation claim. In this case, however, it was apparent that this worker was intentionally trying to hide the history of problems with her right elbow in hopes of having work comp coverage foot the bill.      

The matter was referred to the Los Angeles County District Attorney’s Office. Following their investigation, criminal charges were filed against the education assistant. This worker is presumed innocent until found guilty in a court of law. ICW Group will continue to cooperate with law enforcement as this matter moves forward. 

Christopher Dill
Christopher Dill
Christopher Dill is the Special Investigations Unit Director at ICW Group Insurance Company. A Fraud Claims Law Specialist designee, he was a recipient of the National Health Care Anti-Fraud Association’s Investigation of the Year Award for his significant contribution to the successful resolution of “Operation Back Lash” – one of the largest workers’ compensation health care bribery schemes ever uncovered in San Diego County. Christopher has participated in over 30 criminal cases surrounding medical and legal providers attempting to defraud the Workers’ Compensation system. Christopher’s approach to insurance fraud investigations is a holistic one. From preventative education campaigns, to data analytics, to time tested investigative, and intelligence gathering techniques, it is Christopher’s belief that a multi-faceted approach to insurance fraud is necessary to a successful defense.

Related Articles

ICW Group’s Anti-Fraud Team is Top of Its Field

ICW Group remains at the forefront of industry trends, scams, and exposures within the insurance community. Our entire Special Investigations Unit (SIU) staff are members of multiple anti-fraud trade associations,...

Watch for These Common Scams

Did you know the first recorded scam dates back to 300 B.C.? That’s right. Over 2,000 years ago! It's believed that Hegestratos, a Greek sea merchant, purchased an insurance policy on...

Fast Food Employee’s Work Comp Claim Doesn’t Stack Up

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...