On May 8, 2019, having committed insurance fraud by lying about prior injuries and medical treatment to a PQME, an applicant pled no contest in the County of Sonoma to one count of insurance fraud under Insurance Code 1871.4(a)(1).
The applicant had claimed a neck and right shoulder injury via cumulative trauma through October 2015. Prior to the case being referred to DGC, the applicant was evaluated by a PQME. In that evaluation, the applicant falsely stated she had never had prior injuries to her right shoulder or neck and had never been involved in a motor vehicle accident. Based on that history, the PQME issued a report finding PD, with no non-industrial apportionment. Defendants began paying PDAs consistent with the rating. The case was then referred to DGC for finalization of stipulations at 15% PD.
However, when reviewing the file materials provided by the client, it became clear that the applicant had grossly misrepresented her medical and litigation history. She had been involved in a MVA resulting in neck pain in 2003. She had also filed a workers’ compensation claim for her right shoulder in 2006 while working for a different employer and had received substantial medical treatment. The medical records also showed that she had been involved in a MVA about 4 months prior to the industrial injury resulting in a whiplash injury to her neck. The applicant continued treating for the neck injury from the MVA until the day after her alleged work injury, at which time she commenced telling her workers’ compensation evaluators that she did not have prior injuries or symptoms. DGC’s Jonathan Freeman recommended a supplemental report to address apportionment before proceeding with stipulations, and recommended the filing of an FD-1.
After Jonathan cleared a cover letter and provided the PQME with these records, he reduced the rating by finding non-industrial apportionment to all body parts. Defendant by that time had a substantial PD overpayment due to the applicant’s material misrepresentations, and this formed the damages of the fraud case which was filed by the DA’s office in the County of Sonoma.
The applicant stipulated to restitution in the amount of $5,145.65, was sentenced to 75 days in jail with the option of entering a work release program, and was put on probation for 36 months.
You can read the redacted Minute Orders below.
Minute Orders – Superior Court of California, County of Sonoma: Click here
David Jankosky, Director of Client Services, DGC Attorneys
firstname.lastname@example.org / (818) 654-9911, Ex. 1231