The whole point of Workers Compensation insurance is to pay benefits to people who have been injured on the job, and cannot work. But what if someone is not really injured, and actually can still work? If they claim they are unable to work and collect benefits, but ARE able to work, that is known as insurance fraud and it is a crime. Some people even take it a step further, by filing a claim of total disability and collecting benefits, while at the same time going out and getting another job.



When a case has indicators of possible fraud, an investigator is often brought in to find out the true facts. DMA Claims Services (http://www.dmaclaims.com) investigates suspicious cases, conducts surveillance, and if an insurance claim is found to be fraudulent, turns the information over to the insurance company.

This is a case from the DMA Claims Services Investigations archives, Part 8 of the Fraud Chronicles, where the investigators had to endure hazard to their stomach linings for the sake of the bust.

Greasy Spoon Film Busts Fraudster

By John Crittenden, Investigations Supervisor, DMA Claims Services San Bernardino

"Our subject in this investigation claimed that his injured condition caused him to be unable to sit or stand for more than 10 minutes at a time, due to his restricted range of motion.

"My chief investigator had seen him leave his apartment and tailed him to a rather seedy looking restaurant, where he disappeared inside. It was morning and the restaurant was closed, leading to a pretty good bet that our subject was working there, probably off the books. Our investigator was too conspicuous to hang out in this neighborhood, and had already gotten a thorough look-over by a car full of unknowns. He called in and got out of there.

"We decided that we would not take a chance on our investigator having been 'made' (i.e., spotted as an investigator by the subject) but we were not about to pass up this potential bust. Unfortunately the only way to see what was happening with our subject inside was to have lunch at this greasy spoon.

"I would never have been in this restaurant in the first place, if it had not been the only way to bust our subject. This was not a restaurant that a normally cautious, health-conscious person such as myself would frequent, since it was neither clean nor did it inspire confidence with regard to the protein sources for the main dishes.

"We also had to rig up our body camera to operate out of a shirt pocket. The surveillance was going to be sufficiently complicated that I decided to go myself (at this point I had not seen the restaurant or I might have thought better of it). I invited several others from the office to come since a group would provide better cover. We all took off to meet our investigator in the parking lot. There we made last minute adjustments to the camera and got a good description of the subject.

"We went into the restaurant and sure enough, there was the subject waiting on tables, cleaning, and stocking food on the buffet. We had no choice but to eat, since we were on the verge of getting great film on the subject. We chose the most innocent looking stuff we could find on the buffet, with each of us pretty much converted to a vegetarian state of mind.

"Twisting and turning, getting up to find some additional napkins, etc., I was able to follow our subject with my shirt pocket camera as he performed his duties. And then fortune smiled on us - our subject came to our table to fill our ice teas and promote future meals at the establishment. The closeups would be wonderful. Naturally we encouraged the idea of large parties of business people showing up and engaged him in several minutes of animated conversation.

"I admit we failed to clean our plates as we made a beeline for the office (but I don't think we missed much in terms of desert). While we spooled the tape and waited to see if everything had worked, intestinal rumblings and protests afflicted each of us. Soon all discomfort was forgotten - the video was perfect and our investigator gave us the final confirmation that we had the right guy.

"The examiner and defense attorney loved the tape and turned the subject in for fraud after getting the claim thrown out."

Another victory for truth, justice and lower insurance premiums.