SIU Today Summer 2021 - 16

Doctors providing treatment for both claims had specifically
asked Johnson if she had other employers or had suffered any
previous injuries; she denied concurrent employment and
any prior back injury. On health history forms, Johnson had
marked " no other source of employment. "
THE FRAUD REFERRAL
Based on the evidence including both claim forms (DWC1),
medical records from both claims and the material
misrepresentations made by claimant to medical providers,
VRC Investigations' SIU determined the claim warranted
referral to law enforcement for suspicion of workers'
compensation fraud. A review of benefits paid by Goodwill
confirmed that Johnson had received total temporary disability
benefits between July 13, 2013, and November 16, 2014, that
would not have been paid had she been honest about filing a
claim for an injury to the same body part one day earlier with a
concurrent employer. The benefits paid resulted from material
misrepresentations and were therefore a suspected theft of
benefits. VRC's SIU unit packaged the evidence and presented
the suspected fraud referral to the San Bernardino County
District Attorney's Office and the California Department of
Insurance. The suspected fraud referral documented a theft
of temporary total disability. VRC Investigations prepared a
restitution proposal that included the amount of suspected
theft plus the costs incurred to prove the fraud as recovery,
which is permissible under California law.
The San Bernardino District Attorney's Office reviewed the
documented referral and opened a criminal investigation. On
May 9, 2015, investigators from the Workers' Compensation
Fraud Unit of the San
Bernardino County District
Attorney's Office interviewed
Johnson about her two workers'
compensation claims, filed
with two separate employers
with whom she was working
concurrently.
Johnson told
investigators she had been
employed by Goodwill, and
that she filed a claim for a back
injury which had occurred on
July 12, 2013. She denied any
concurrent employment while
working for Goodwill. Johnson
admitted that she had been
hired by ASM and had trained
for a position but claimed that she had not officially worked
for the company. Employment records proved that to be a
misrepresentation. Johnson said she had advised her supervisor
at ASM that she had sustained an injury, but that the injury
did not happen at Sam's Club, her work location. Johnson
alleged that her supervisor at ASM forced her to file workers'
16 SIU TODAY | SUMMER 2021
compensation paperwork with ASM despite her alleging that
the injury did not occur with the company.
The San Bernardino District Attorney determined there
was sufficient evidence to file four felony criminal charges
against Johnson for worker's compensation fraud. The charges
consisted of two counts of knowingly presenting a fraudulent
claim for the payment of a loss or injury on July 18, 2013, and
July 31, 2013 (Penal Code Section 550(a)(1)), and two counts
of making a knowingly false material representation for the
purpose of obtaining workers' compensation benefit (Insurance
Code Section 1871.4(a)(1)).
Johnson was arrested and pleaded not guilty to the charges, and
the case ultimately went to a jury trial. Prosecutors submitted
copies of the workers' compensation claim forms filed by
Johnson, noting that one of them claimed she sustained a
back injury on July 12, 2013, while working at Goodwill,
while the other claimed she sustained a back injury on July
11, 2013, while working for ASM. One of the doctors who
treated Johnson testified that he had asked if she had any other
employers or had suffered any previous injuries, and that she
failed to provide any information in response. The doctor
specifically testified it was important for him to know about
other injuries to determine the best course of treatment and
appropriate benefits. A nurse practitioner who treated Johnson
testified that she was required to gather information regarding
her health background, and that Johnson indicated that she had
no concurrent employment, and that she had never previously
injured her lower back or had any prior pain in her back. The
insurers for both Goodwill and ASM paid a total of $114,342.09
in benefits on the two claims.
PROCEDURAL HISTORY
A jury found Johnson guilty on all four counts of workers'
compensation fraud. The jury also found that, under the
aggravated white collar crime enhancement, the offenses in
counts one through four resulted in the loss of more than
$100,000 (Penal Code Section 186.11(a)(3)). The trial court
SIU Today Summer 2021

Table of Contents for the Digital Edition of SIU Today Summer 2021
