Well, dear readers, the week is just zipping right by and the weekend is coming up fast!

Long-time readers of this blog will know I offer the Latin quote, “Quis custodiet ipsoscustodes?” with some frequency, and I really shouldn’t. Law enforcement is entrusted with a lot by society, not just with safety but with honesty. How can those we trust to protect us from criminals engage in crime themselves?

Sadly, we have, all too frequently, seen law enforcement officers engage in the very fraud we would want them to help investigate, catch, and prosecute.

In the long standing tradition of this most humble of blogs, we won’t be naming names, but it appears a former CHP captain was arrested on allegations of workers’ compensation fraud recently. The accused was out on workers’ compensation leave when he was observed engaging in activities “inconsistent with limitations” reported to his treating physicians.

Of course, the typical workers’ compensation claim involves the treating physician asking the injured worker about his or her limitations, and then, under medical reason, imposing work restrictions within those limitations. Those work restrictions often enough preclude continued work which generates the right to temporary disability benefits.

Your humble blogger is not jumping to any conclusions about this particular case, but such fraud robs the citizenry of their tax dollars through unwarranted benefits. When such fraud is the result of actions by law enforcement, that raises a question: is this particular law enforcement officer credible and honest?

When the LEO is not honest – when a court determines that he or she has engaged in fraud – it raises a question that is not as applicable or devastating for a common civilian’s fraud: how many convictions were obtained by statements or testimony from that particular law enforcement officer? How many convicts can now challenge their convictions and demand new trials based on this “new evidence” that the officer who testified in their trials should not have been trusted by Judge and Jury?

Your humble blogger hopes for a swift investigation and that the truth is discovered through our adversarial legal process. But this instances serves as a reminder for us all – we must be vigilant in all instances. Hopefully, the fallout from such cases imposes upon all law enforcement officers their obligations and duties and how critical that trust is that we put into them every day.

The Sacramento County District Attorney’s office announced that fraudster Gustavo Cisneros has pled no contest to felony insurance fraud.

According to this press release, “Cisneros had at least six previous workers’ compensation claims.  In these claims, Cisneros used different social security numbers and dates of birth to make his actions more difficult to detect.”  The sentence for this fraud is 150 days in county jail, 2 years of formal probation, and restitution to the victim.

As always, your humble blogger is happy to see that the fraud has been detected and that the prosecutor has taken up the case.  However, this is far from a perfect result.

Only a fraction of the fraud referrals sent to the district attorney’s office are taken up. 

But this tactic used by Cisneros is not uncommon.  Often enough, we see applicant’s represented by the same applicant attorney filing claims with “typos” on the date of birth or the spelling of the name.  If you’re a cynic like your humble blogger, there’s no “error” here but a deliberate effort to conceal prior claims. 

The WCAB appears to offer no remedy for this – there is no penalty for an incorrect DOB, social security number, or failing to list prior workers’ compensation claims or injuries in paragraph 8 of the application. 

Certainly, defendants can explore this with a deposition or an ISO report, but these methods take time and carry their own expense.  Furthermore, even when these discovery methods are used, when you have an applicant such as Cisneros who is actively trying to avoid detection of prior claims and is willing to engage in fraud, a deposition under oath is of limited assistance. 

What are the remedies that are available for such issues?

When it is the allegedly injured worker filing the application, a government photo ID would address some of these issues, especially if the failure of the pleadings to conform to the government ID data (date of birth, spelling of name, etc.) is a basis to dismiss the application.

Furthermore, when an applicant attorney is involved, perhaps the failure to disclose prior WC claims for which the same firm represented the same applicant should be sanctionable.  If an applicant attorney assumes representation after an application has been filed, an amended application listing prior claims for which the same firm represented the same applicant can be filed within 45 days of assuming representation.

I defer to the wisdom of the legislature and the WCAB if the added burdens on applicants and their attorneys from the suggestions above outweigh the public’s interest in deterring and preventing fraud and reducing the delays and costs of workers’ compensation litigation.

What do you think, dear readers? 

Have a great weekend!

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!

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!