Workers’ compensation fraud is a problem that affects companies nationwide. While fraud convictions are rare, Athens Administrators takes an aggressive approach in reviewing claims made by employees. Our highly skilled Special Investigative Unit (SIU) is trained in uncovering evidence of fraud. With extensive law enforcement and surveillance backgrounds, SIU investigators recognize that each unique case demands varying levels of analysis and management. Recently, Athens’ diligence has resulted in three formal charges of workers’ compensation fraud.
Case 1: In one such case, surveillance played a critical role in detecting nine felony counts of insurance fraud. Athens’ SIU obtained hours of video evidence that depicted the claimant performing various physical activities. This evidence contradicted prior statements he had made to his treating doctors. As part of Athens’ SIU action plan, the claimant’s doctors — along with the Association for Manufacturing Excellence — reviewed our evidence and agreed that “the applicant [was] grossly magnifying his complaints . . . There is no indication for work restrictions of any kind.” As a result, the case was formally filed with the California Department of Insurance Fraud Division, as well as the Los Angeles County District Attorney’s Office.
Case 2: Surveillance was again utilized in a similar incident, in which the claimant alleged to have suffered a work-related injury. However, SIU video evidence showed the claimant engaging in significant outside physical activities, such as operating a lawnmower, bending, reaching and stooping. After reviewing the footage, her treating doctor released the claimant from care, returning her to work full-time with no restrictions. The case has since been accepted for criminal investigation and presented to the Yolo County District Attorney’s Office for consideration of criminal charges.
Case 3: In a third instance, an ISO search revealed that the claimant in question had previously made several similar workers’ compensation claims. Although he used a cane at medical examinations, surveillance found that the claimant ambulated without the use of a cane outside of scheduled appointments. After reviewing the evidence, doctors agreed that “there [was] virtually no reason to continue treatment.” A thorough investigation by detectives followed, which included interviewing the Senior Claims Examiner, subrosa investigators as well as the treating doctors. As a result, the Los Angeles County District Attorney’s Office charged the claimant with two felony counts, ultimately leading to his arrest.
At Athens Administrators, we know that identifying fraudulent workers’ compensation claims starts with a well-managed response. Our experience, capabilities and partnership with expert investigators allow us to proactively respond to and efficiently handle cases of fraud, wherever they arise.