Evelyn Tolentino, a 37-year-old Medical Assistant, alleged an unwitnessed industrial injury to her left knee, left hip and left ankle after allegedly falling from a ladder while working for Evelyn Jankowski, M.D. Her workers’ compensation claim was accepted, and benefits were being administered. Tolentino presented to her QME with crutches and a limp and explained she must use crutches and could not put her foot down to complete exam. Multiple days of surveillance were obtained which depicted Tolentino utilizing a crutch and having a limp only at her scheduled medical appointments, and all other days of surveillance depicted Tolentino walking with a normal gait, without crutches or a limp. The surveillance film was submitted to the QME who opined that, based on the surveillance film, the injury appeared minimal at best. The QME provided the claimant with a 0% impairment rating, resulting in an attempted theft of permanent disability as the Primary Treating Physician had previously provided a 41% impairment rating.
The contrast between Tolentino’s presentation at a medical appointments and other days of surveillance prompted a referral to VRC Investigations’ Special Investigation Unit for review. VRC’s SIU team submitted a fraud referral to the Los Angeles County District Attorney’s Office and the CA Department of Insurance for suspected Workers’ Compensation fraud, resulting in the opening of a criminal investigation with the Los Angeles County District Attorney. The Los Angeles County District Attorney then filed criminal charges against Tolentino to include 1 Felony count of CA Insurance Code 1871.4(a)(1). On October 6, 2020, Tolentino pled No Contest to felony IC 1871.4(a)(1) and agreed to the restitution order of $32,923.
Insurance fraud is a serious crime and a Coalition Against Insurance Fraud survey found that 3 out of 4 insurance carriers note insurance fraud is increased. Contact Dalene Bartholomew, CFE, CIFI, VP at VRC Investigations to learn more or discuss your fraud abatement program. email@example.com
Dalene Bartholomew CFE, CIFI
Vice President | VRC Investigations
Phone: 800-654-2185 option 7