July 28, 2021 •Dalene Bartholomew, CFE, CIFI, VP
Back-related injuries are a challenge for fire departments, creating unexpected absences and worker’s compensations claims of about $10,000 on average. So it was not unprecedented in 2014 when a 30-year-old firefighter in Redwood City, California, alleged a lower back injury from pulling a hose. California Labor Code 4850 provides eligible public employees with a paid leave of absence for up to one year after sustaining a temporary total disability from an injury arising from the course of his or her duties. The claimant, Alison Himsl, collected these benefits and eventually retired, forcing the city to set aside reserves of millions of dollars for lifetime benefits.
The claim adjuster requested an investigation. Social media and surveillance video showed the claimant at a gym, dead-lifting weights of approximately 100 pounds and doing CrossFit routines. The case was assigned to VRC’s Special Investigation Unit for suspicion of fraud.
The claimant had testified that she had no back problems prior to the alleged injury and denied any prior treatments. VRC’s medical canvass searched for prior medical records in California and Arizona. Facilities were located where the claimant had been previously treated. Subpoenaed medical records provided evidence of prior back issues as far back as 2006, including extensive treatment for pain management and evaluation for surgery. In fact, the claimant had been treated 25 times for back issues in the year before the injury.
After reviewing these records and commenting on the claimant’s questionable credibility, the medical examiner reduced the benefits apportionment from 75% to 25% industrial, resulting in an attempted theft of benefits of $16,965. VRC’s SIU noted that material misrepresentations had been made to receive benefits for which the claimant was not entitled. As a result, a suspected fraud referral was presented to the San Mateo County District Attorney. After a criminal investigation, seven counts of insurance fraud were filed for multiple felonies.
VRC’s restitution proposal covered the theft of benefits plus the cost of proving the fraud. In May 2021 the claimant pled guilty to four counts of fraud and was ordered to pay the full amount of restitution, $70,000, up front. With restitution paid in full to the employer, the City of Redwood City, California, the criminal charge was reduced from a felony to a misdemeanor.
It’s not enough just to spot red flags – evidence must be admissible in court, and investigations must be comprehensive. This is another case where VRC delivered full restitution and saved an employer a sizable reserve for unwarranted lifetime benefits. Diligence is the best way to fight fraud. Put VRC’s investigative experts to work for you today.
“Cause, Type, And Worker’s Compensation Costs Of Injury To Fire Fighters,” American Journal of Industrial Medicine, March 13, 2003, https://doi.org/10.1002/ajim.10200
DALENE BARTHOLOMEW, CFE, CIFI
Dalene Bartholomew is a Certified Insurance Fraud Investigator, Certified Fraud Examiner, Vice President of VRC Investigations. She enjoys building long-term strategic partnerships with insurance carriers, employers and TPAs and providing innovative insurance fraud solutions and fraud abatement programs resulting in hundreds of insurance fraud prosecutions nationwide. A forward-thinking senior executive with a 20-year record of success combatting all lines of insurance fraud, she was awarded “Fraud Fighter of the Year” by the Anti-Fraud Alliance. A recognized speaker, author, insurance fraud specialist, expert witness, fraud advisory board member, and wine enthusiast. DaleneB@VRCinvestigations.com