WCDefenseCA

Hey there dear readers! How was your Halloween?  Did you put on the costumes and do the trick or treating?

Your humble blogger took his lovely children door to door trick or treating.  The sad thing is, of course, the futility of it all.  Every family in my neighborhood went to Costco and bought the same bag of candy, and, of course, all our respective children collected each others’ candy.  The end result? I have the same candy I put out in front of my house. 

Anywho, as spooky and scary as Halloween can be for the kids, California celebrates Halloween every day when it comes to terrifying its poor, wretched, disenfranchised employers.

Not only is there no way to opt out of the workers’ compensation system, which, in California, so effortlessly delivers benefits to vendors, attorneys, treaters, and lien claimants, but also when trying to obtain said necessary insurance, employers can also fall prey to fraud.

Your humble blogger doesn’t like to name names absent convictions, as accusations are so easy to make and so hard to prove.  Your humble blogger has been accused of the world’s most handsome man in a bow tie, although the charges are yet to stick.  So, an insurance agent has been accused of pocketing insurance premiums and producing false certificates of insurance for businesses.

What happens when an employer with one of those dummy policies has a claim brought against it before the WCAB?  While this might be good cause to avoid the criminal penalties and sanctions, the WCAB is not going to force any insurance company to pick up coverage.  In California, this isn’t throwing an employer into the water without a life jacket… this is throwing an employer out of a plane without a parashoot.

What can employers do to combat the sort of fraud as is alleged in the linked story?  Well, for one thing, you can always check on coverage by doing an information WC Coverage Inquiry here.   Upon receiving the insurance certificate, employers should also verify coverage by reaching out directly to the insurance company listed on the policy to verify the policy number and locations covered.

So you see dear readers?  If you’re an employer in California, it’s Halloween all year round and it’s never “treat,” just “trick” or “horribly crippling costs driving you towards bankruptcy or to leave the state.”

In other words, dear readers, your humble blogger suggests that you keep on the sunny side of life!

Till Friday…

Well there dear readers, we made it to another Friday!  What better way to end another week than with a post on workers’ compensation fraud?

Well, in this case, it’s only alleged fraud.  My long-time readers will recall that your humble blogger doesn’t like to name names when there has been no conviction. 

But, even the fact that charges have been filed can provide an educational moment for us in the workers’ compensation world.

As alleged, the criminal defendant committed workers’ compensation fraud going back several years.  Some of the related news reports allege up to $500,000 in fraudulently received benefits, and, of course, there was the cost of the investigation itself, which included several hours of surveillance and obtaining and reviewing medical reports.

Let’s just say, hypothetically, that there is some guilt on the part of the criminal defendant – exaggerating symptoms to receive TD and medical benefits or lighter work duties, what have you.  What’s the best defense for employers when this happens?  In this case, the alleged fraudster was a former correctional deputy in the employ of Tehama County.

Well, the reason that there was an investigation is that a source within the Sherriff’s department noticed the defendant’s activities and reported them as she was out on industrial leave at the time.

Sometimes we catch fraud by a gut feeling or intuition that tells us to conduct sub rosa.  When that gut feeling isn’t there, however, co-workers, employees, and honest community members can often be the cape-less heroes in spotting and reporting workers’ compensation fraud.

Certainly, we should let justice take its course and see if there will be a guilty plea, a conviction, or an acquittal.  However, whether the criminal defendant in this case is guilty or not, this instance serves as a reminder for us all to remain vigilant and investigate leads when they come our way.  If those involved in law enforcement can engage in actions that give rise to charges of fraud… who couldn’t?

Have a great weekend, dear readers!

How does it feel, dear readers? You made it to the first Friday of 2023. So far, the world appears to have remained intact, which is a welcome surprise for your humble blogger. What better way is there to end the first week of the new year, than a story about workers’ comp fraud?

Randy Rosen, who ran Wellness Wave in Beverly Hills has plead guilty to submitting fraudulent insurance claims. According to the Mercury News, Mr. Rosen’s girlfriend, Ms. Liza Vismanos, owned Lotus Laboratories and engaged in similar activities, pleading guilty to insurance fraud.

So if you have any liens or bills outstanding from either of these organizations, now might be a good time to consider what impact the guilty pleas have on the likelihood of the lien claimants prevailing at trial.

It should also serve as a reminder for us all that we must be diligent in looking out for, reporting, and prosecuting fraud.

Until next time, dear readers!

If a car is ever invented that uses cynicism for fuel, California’s workers’ compensation system will likely serve as the mother lode for this amply abundant resource. 

Your humble blogger has heard countless accusations from bitter applicant attorneys that the only reason to go to trial instead of stipulating to 100% in every case is so that defense attorneys can bill more.  How often have we heard that insurance companies are lighting Cuban cigars with $100 bills paid for by the suffering of injured workers?  And certainly, there is no such thing as employee workers’ compensation fraud – it’s always just the employers using misinformation to poison the well of public discourse.  Nonsense, certainly, but there’s plenty of it to go around.

Well, the defense community has its cynics too, particularly about suspected but rarely proven schemes where certain applicant attorneys and vendors are in the cahootiest of cahoots to enrich themselves not by obtaining appropriate benefits for injured workers, but by scamming the system at the expense of consumers.

It’s often a jolt to the system when there is an investigation and a conviction of such a scheme, but it happens now and then.  It appears that Jon Woods, Esq., has been convicted of 37 felony counts of insurance fraud and sentenced to four years in state prison and ordered to pay restitution to several insurance carriers. 

New Santa Ana reports on a scheme to charge attorneys and vendors fees for referrals of clients.  As alleged, Jon Woods also worked with Edgar Gonzalez, using his subpoena company, USA Photocopy, in exchange for having various business expenses of Mr. Woods paid for by Mr. Gonzalez.

So, besides getting deeper entrenched in our cynicism and convictions that there is a giant conspiracy out there to defraud every workers’ compensation defendant, what can we do?

Well, if you have liens from USA Photocopy, you may want to question them and look closer based on these revelations.  Furthermore, in any case where you have any subpoena service with a lien which also has or had Mr. Woods as the applicant attorney of record, you may want to consider looking closer at the basis for the subpoenas.  This conviction suggests that if one apple in the barrel was rotten, the rest may have turned too.

Don’t let this sour you, dear readers.  This is a reason to be ever vigilant against fraud, but not to see it everywhere.  There are actual employees in California.  Those employees do, on occasion, actually sustain injuries.  And, upon seeing the benefits notices and the panel process, not to mention being seen by a particularly grumpy workers’ compensation clinic doctor, some of those actual employees with actual injuries might actually seek legal counsel.

The vast majority of the cases we deal with are not fraud, so let’s let this story fuel our attentiveness and our determination to catch dirty hands in cookie jars when the situation calls for it.  Your humble blogger, as always, remains eager and willing to cheer you on in doing just that.

Happy Monday, dear readers!

Your humble blogger trusts you are soaking in the summer sun, enjoying the fresh air and relaxing atmosphere that pervades when we are not all cooped up inside during the cold weather.

But, when you aren’t outside enjoying the sun, what’s good to watch on TV?  Your humble blogger’s current favorite show is Yellowstone, where Kevin Costner holds on to a family ranch against all sorts of adversaries, reminiscing of simpler times when he would dance with wolves, bring America back from an apocalyptic hellscape by delivering mail, or adapt the plot of Mad Max to an aquarium.

So, having found a show I really, really like, I was hurt to find out that one of the actresses on the show, who plays a lawyer of all people, has been charged with workers’ compensation fraud!

Now, your humble blogger doesn’t like to name names, but if you’re really curious about who has been charged, feel free to follow this link.  The actress is charged with felony workers’ compensation fraud and the allegations are that she received almost over $95,000 in temporary disability benefits, but also worked on the set of Yellowstone for four episodes.

Of course, the actress denies that she did anything wrong and has retained counsel, and, as it should be – the burden remains squarely upon the prosecution to prove its case beyond a reasonable doubt, and, until then, she is presumed not guilty.  That being said, there are some parallels we see in situations similar to this without the glamour of Hollywood as a backdrop.

How often, dear readers, have you read a deposition transcript wherein a construction worker will claim to be temporarily disabled until he finds work, and the moment a project is finished he goes back to TTD claims until the next project comes along?  How often, dear readers, have employers been unwittingly dragged into contribution proceedings because their new hire was actually on TTD for a prior employer, and then that prior employer claimed that the post-injury work has aggravated the condition?

Some workers use TTD benefits as stopgaps for being out of work – not for periods of medical recovery as intended, but for periods where work is unavailable.  The consequences are dire for employers of course – added litigation, aggravated injuries, contribution proceedings.

Your humble blogger certainly hopes the truth will come to light in this Yellowstone case and justice will be done, but this case, particularly with its prominence due to the greater context of a popular TV show, should remind us all to be extra vigilant when TD seems to be going on for a little bit too long.

Now, if my beloved readers will excuse your humble blogger, I’m going to go get fitted for a litigation-appropriate cowboy hat and get ready to catch the 6666 spinoff when it finally comes out.

Until next time, dear readers!

Happy Wednesday dear readers!

Your humble blogger hopes the past weekend, longer than usual, was a time of rest and reflection for you all.  But, as we find ourselves back in the thick of it, with the temperatures rising and the children brimming with excitement for the summer months to release them from school and dropped into the freedom of leisure activities, how about a blog post?

I bring you the story of another “successful” fraud prosecution, this one of Yeimi Espinoza, as reported by WorkCompCentral.  Ms. Espinoza plead guilty to one count of “concealing or failing to disclose an event in order to receive benefits.”  To wit, she testified at deposition that she had no other employment even though surveillance conducted on the day of her deposition showed he working in a field before driving to her deposition.

She was ordered to pay $11,238 in restitution and was placed on probation for one year.

The trigger for the investigation? According to Intercare and WorkCompCentral, convict Espinoza was “reportedly observed working in a blueberry field.”  That’s a lucky catch and not a systemic response.

While this certainly may have helped offset some of the wrongfully imposed costs on her employer’s insurer and likely damaged her credibility as to her claim, your humble blogger must sadly reflect that this result seems a limited deterrence effect to the workers’ compensation population at large.  When one is caught with one’s hand in the cookie jar, simply releasing the cookie and going on as if nothing happened is unlikely to dissuade the next cookie bandit.

Your humble blogger hopes that in the future, we can see the California legislature take a break from its crusade to drive out any remaining business in California to help protect the population at large from fraud.  As we all know, workers’ compensation fraud has a seemingly endless list of victims.  Insurers and employers are cheated of resources.  Employees with legitimate claims are seem more skeptically because of the prevalence of fraud.  Prices on consumers go up to cover the cost of absorbing, investigating, litigating, and punishing fraud.

Your humble blogger tips his proverbial hat to Intercare for investigating and referring this case and to the District Attorney for taking the case up and prosecuting it.  Another reminder to our never-ending duty of vigilance.

Straight on to Friday, dear readers!

Happy Monday, dear readers, and, perhaps more importantly, happy Valentines’ Day!

For those of you brooding this Valentines’ day, frustrated with a broken heart or an evil ex, perhaps your humble blogger can brighten your day with a story of justice being done?

Here we are again and your humble blogger wants you to check your files for the name of George Demetrius Karalis.

Who is Dr. Karalis?  Well, he’s the latest exhibit in your humble blogger’s case for why we must be suspicious and thorough of every player in workers’ compensation, even the doctors.

Karalis was a psychiatrist in San Francisco who recently plead guilty to workers’ compensation fraud and ordered to pay $1.4 million in restitution and serve 120 days in jail.  As alleged, he coached federal workers’ compensation claimants on what to say in order to get benefits to which they were not entitled.

Although the discovered fraud pertained primarily to federal employees, it might be worth it to check to see if any of your treatment reports or liens or even AME reports are based on his opinions. 

So, dear readers, are you keeping an eye on your repeat-player med-legal and treating physicians?  Are there parts of the report that you could swear are copy-pastes of other reports?  Do your claimants go into their visit one way and come out with completely new symptoms and complaints?  These are akin to a Soviet military parade – lots of red flags!

Perhaps noticing such patterns is a good reason to investigate further.

Straight on till Wednesday, dear readers!

Happy Wednesday dear readers!

Well, another week and another bit of news just to help us appreciate the various dangers facing employers in California. 

The Department of Insurance reports the sentencing of Karyl Lynn Reed for various fraud charges stemming from operating as an unlicensed insurance agent.  According to the press release, she collected premiums through Envoy Business Partners and Allenn Specialty Group.   She issued bogus Certificates of Insurance.  Her victims paid for the policies and operated thinking they were covered by a workers’ compensation policy when, in fact, they were uninsured.

Of course, aside from running a business and having to be on the lookout for fraudulent workers’ compensation claims made by employees (or alleged employees), California’s employers must also be on guard for the other side of the equation —  fraudulent insurance agents leaving employers exposed when on-the-job injuries occur.

If you’re considering engaging an insurance broker for a policy there are a few things you can do to verify that you are actually covered.  For one, ask to see the insurance agent’s license and run the credentials through the state’s license verification website.  Another step to take is, upon receiving a certificate of insurance and confirmation that the premium is paid, contact your insurance company directly and confirm that a valid policy exists for your business. 

Your humble blogger has represented parties alleged to have been illegally uninsured for workers’ compensation at the time of injury, and if you thought the deck was stacked against an insured employer, it is doubly so for an employer forced to unexpectedly adjust and defend a claim without the resources and expertise of a claims adjuster.  Exposure to severe penalties and costs await any employer so unfortunate as to find itself on the receiving end of an allegedly uninsured claim.

Your humble blogger tips his hat to justice being done – the sentence is four years in prison and a restitution order of more than $1.4 million – and hopes we can all profit from this news to remain vigilant from all sides.

A little-known fact about your humble blogger, dear readers, is that for a short part of my law school career, I studied how to grow rice.  I was the best, though no one knew it.  My rice was the riciest rice that ever riced.  However, when I submitted my rice for inspection in our law school rice growing class, the totally biased and unfair rice grader gave my rice an F.  Since the day of that totally true story that absolutely happened and is not just a ludicrous introduction to a blog post, I have always looked for justice being visited upon rice graders.  Well, at long last…

Brooke Gomez of Maxwell, California, a rice grader (see how I set that up?) has plead no contest to a misdemeanor fraud charge and was sentenced to 12 months of probation and ordered to pay restitution to her employer.

Convict-Gomez sustained an admitted injury, but co-workers reported her working as a bartender.  Meanwhile, she was collecting temporary disability benefits. 

The reports lead to eventual undercover investigators observing applicant serving drinks and counting money, as well as wiping down the bar.  In a twist worthy of a sit-com TV show, applicant discussed with patrons her pending workers’ compensation case and her hopes that she would not be discovered while working!

Fortunately, the other employees did the right thing and reported the fraud.  Fortunately, the case was picked up by the prosecution and brought to a plea of no contest.  Unfortunately, not all fraud is detected or even punished.

Although the criminal-defendant will have to make restitution, 12-month probation is hardly a deterrent for future similar activity.  At best, her next workers’ compensation claim will receive considerable scrutiny given her history.  Here’s hoping, at least!

Till next time, dear readers!

Happy Friday, dear readers!

Here we are again: another week is wrapping up, and another blog post about alleged workers’ compensation fraud by one of the community’s heroes.

Now, as always, your humble blogger must preface this by saying the fraud is only alleged.  No one has been convicted at this point, which is why your humble blogger declines to name names.  That being said, the allegations are illustrative for our own case-loads, and why we must be ever vigilant for fraud.

A firefighter for the City of Hollister has been charged with four felony counts including workers’ compensation fraud after he was caught, allegedly, working a second job while collecting temporary disability benefits.  As claimed by the prosecution, the firefighter had about nine months of collecting a second paycheck while still receiving temporary disability benefits.  He denied post-injury employment in a deposition.

Your humble blogger hopes the truth comes out and justice is served, of course, but bear with me a moment while we contemplate the implications if the prosecution is correct in all its charges and factual allegations.

In such a scenario, the firefighter has cheated the taxpayers by collecting money on TD to which he was not entitled.  He has cheated the taxpayers a second time by likely aggravating his condition through continued work, necessitating additional medical treatment.  He has cheated the taxpayers a third time by increasing the administrative costs of addressing his workers’ compensation claim, including investigation and prosecution.  And he has cheated the taxpayers a fourth time, by dishonoring his profession and poisoning the respect and admiration held for the firefighters all over California, who so regularly put themselves in harms way to the benefit of us all.

But the harm doesn’t stop there.  If this firefighter lied to his post-injury employer about the need for accommodations, the employer is likely exposed to a potential claim from the City of Hollister’s fire department for reimbursement or an application alleging a cumulative trauma for that period.  The subsequent employer is likely taken by surprise and now has increased workers’ compensation premiums to look forward to.

Let this be a reminder to us all – no human being, no matter how generously he or she is compensated, and no matter how otherwise noble or honorable his or her profession, is with certainty beyond the pull of greed and beyond the enticement of deceit.  While the injured worker’s occupation certainly matters when it comes to rating out permanent disability, it has no bearing on the level of vigilance that is called for in defending a claim.

Have a good weekend, dear readers.  Let those of us who can sleep the sleep of the just.