August 4, 2021 •Dalene Bartholomew, CFE, CIFI, VP
A pain level of six on a 10-point scale is considered moderately strong, a pain that interferes with normal daily activities and makes it difficult to concentrate. You might think it would make it difficult to run a marathon, much less ride an elephant, but those were two of the more unusual features of the case of a schoolteacher in Kern County, California.
On September 5, 2017, Denise Jorgensen alleged an unwitnessed industrial injury as a result of transferring a student from a wheelchair to a regular chair. Workers’ compensation benefits were administered and the claimant was treated by an occupational health provider. The claimant reported back pain presenting as a constant aching pain at 6/10 and aggravated by bending and sitting; her lumbar x-ray was noted as normal. She was diagnosed with sprained ligaments of the lumbar spine and received workers’ compensation benefits including medical treatment and temporary total disability payments.
The claim was assigned to VRC Investigations for an initial compensability investigation. In a recorded statement, the claimant said she had been inactive since the injury, that she was physically limited, and that she had not gone running. She stated she had not taken a vacation since being off work and denied that any activities other than work could be causing or contributing to her injury.
VRC Investigations obtained medical records revealing that the claimant consulted a medical provider twice within three weeks of the alleged injury, to obtain clearance to travel internationally. VRC’s search of social media uncovered evidence of the claimant’s travel to Africa. Evidence was also secured of the claimant’s participation in the Disneyland Double Dare Marathon in October 2017. She had apparently run both a 10K and a half-marathon less than a month after her alleged injury.
VRC’s Special Investigation Unit met with the claimant’s primary treating physician to provide the social media evidence, the transcription of the claimant’s recorded statement, and the medical records. In a supplemental report the PTP stated, “With all of this information, it makes sense that this patient, more likely than not, fabricated her industrial injury in order to travel to Africa because she didn’t have the time off and looked at this as a way to travel, as she knew that her employer would not accommodate the restrictions.” The physician also noted that the claimant left for Africa amid treatment for her back. The PTP backdated the claimant’s return to work date to a week after the alleged injury.
VRC’s SIU submitted the case to Kern County District Attorney’s office, noting material misrepresentations and significant supporting evidence of the theft of workers’ compensation benefits. A criminal investigation was conducted. On January 8, 2020, the claimant was charged by the Kern County District Attorney’s Office with six felony counts of fraud.
VRC’s restitution proposal covered the theft of benefits plus the cost of proving the fraud. On June 6, 2021 the claimant pled no contest to one count of insurance fraud and was sentenced to one year of probation and $720 in court fines and fees. The Court agreed with VRC’s restitution proposal and ordered the claimant to pay full restitution of $8,954.90 to her employer, the Kern County Superintendent of Schools.
VRC Investigations’ results include hundreds of convictions for worker’s compensation fraud with court orders of over $3 million in restitution. Put VRC’s investigative experts to work for you today.
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