Marta Betancur, a community college custodian, fell while standing on a trash can to retrieve paper towels. Her claim of an industrial injury to multiple body parts was accepted, litigated, and benefits were administered. During her deposition she testified she could not walk without a cane or walker. The Panel Qualified Medical Evaluator (PQME) reported that she used a cane, received assistance from her daughter, and took two full minutes to walk 25 feet during the evaluation. A medical report prepared around the time of her deposition included a notation by the provider that the claimant used a cane, moved slowly and “appeared like a 90-year-old woman.”
Around the deposition, VRC conducted video surveillance over four days. VRC’s investigator captured video while the claimant walked, jogged, attached a trailer to a truck, carried items, climbed a ladder, rode in a boat, and rode on an inflatable tube. For four days, the claimant moved normally, without any hesitation or restriction. She walked with a normal gait, without the use of a cane.
The surveillance video was submitted into evidence. The Primary Treating Physician and the PQME reviewed the video and issued a change in medical opinion and benefits. The PQME commented that the claimant’s representations during the evaluation “differed quite substantially from the objective evidence in the video,” and pointed out that the claimant spent 14 hours on a boat, where she stood and bent without difficulty. The PQME’s revised opinion found the claimant had zero impairment ratings and that she could have returned to her usual and customary occupation on the first date of the surveillance.
VRC’s Special Investigations Unit (SIU) determined an attempted theft of Permanent Disability in the amount of $26,773, along with an actual theft of TTD benefits of $31,529. As a result of misrepresentations made in the deposition and to medical providers, along with theft of benefits determined by the medical providers, VRC’s SIU determined a referral for suspected fraud was warranted.
VRC’s SIU submitted the evidence to the San Francisco County District Attorney’s Office and the California Department of Insurance. A criminal investigation was completed and criminal charges were filed for of attempted perjury, filing a false claim, presenting a false statement, making a false statement in support of a claim, and insurance fraud.
The claimant was arrested and ultimately entered a Guilty Plea to Felony Insurance Fraud. VRC’s SIU coordinated with the District Attorney on the restitution proposal. The claimant was ordered by the Court to complete two years of supervised probation, complete 80 hours of community service and pay $80,000 in restitution.
“Insurance fraud is a multi-billion-dollar crime that has real costs to consumers,” San Francisco District Attorney George Gascón said in a statement to the San Francisco Examiner. “This type of fraud drives up insurance premiums for the rest of us.”
The claimant remitted $80,000 in full restitution payment to the victim and served the 80 hours of community service.
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