A chef alleged an injury to his lumbar spine after lifting a tray of meat and the results of the diagnostic tests, which showed a significant injury, were submitted to Zenith.

Zenith’s Special Investigation Unit (SIU) discovered that the claimant had suffered a motor vehicle accident just five months prior to the alleged spinal injury in the restaurant. In his deposition, however, the claimant consistently denied prior back pain, injury or treatment.

The claimant’s records told a different story and showed extensive medical treatment to the same area of his spine during the months leading up to the reported incident. In fact, when Zenith sent the MRI from the recent claim and the MRI from the motor vehicle accident to a doctor to compare, the doctor found the MRIs to be identical.

In addition to denying any prior injury to his spine, the claimant specifically denied any post-injury employment or income. However, Zenith’s SIU investigation revealed the claimant was employed at a local private school as a transportation coordinator for a six-month period, despite collecting more than $5,000 in temporary disability benefits.

After building a solid case, Zenith’s SIU presented the case to the District Attorney’s office and fraud charges were later filed against the chef.

The Result: The claimant pleaded no contest to one felony count of fraud and was ordered to serve 90 days in jail. The claimant was also given three years felony probation and was ordered to pay restitution.

Because of Zenith’s integrated claims management services and the coordinated efforts of Zenith’s claims, legal and SIU departments, the successful managing of this claim saved what would have added up to thousands of dollars in overall claim costs and resulted in savings that will be passed along to the policyholder.

An employee of a large fruit-tree farm located in the Central Valley of California was formally charged with two felony counts of insurance fraud in a criminal complaint.

The employee filed a workers’ compensation claim two weeks after he had been hired as a tree pruner, alleging an injury to his lower back. He was subsequently placed on temporary total disability (TTD). He received TTD payments until the claimant’s medical treatment and diagnostic tests resulted in negative findings.

After he began missing medical appointments, Zenith opened an investigation. The employee was followed from his residence one morning to a dairy (coincidentally also a Zenith policyholder) where he remained for several hours.

Zenith investigators subsequently made contact with the owners of the dairy. Zenith determined that the claimant had been recently hired at the dairy but under a false name, social security number and date of birth. Shortly after being hired at the dairy, the employee filed yet another workers’ compensation claim alleging an injury to his back.

After Zenith investigators interviewed the employee, the claimant sought legal representation. During his subsequent deposition, the employee denied any prior back injuries or workers' compensation claims.

During a recent-activities check, the claimant was followed to a third place of employment, another dairy, where Zenith investigators determined he was working under a third name, social security number and date of birth.

The Result: Prosecutors arrested the claimant on felony charges of insurance fraud and identity theft.

An employee alleged he injured his back while bending over to pick up saw horses on a job site. During the course of the claim, the claimant denied to Zenith and treating physicians that he had any previous medical history of back pain or back injury requiring medical treatment. He denied several times during his sworn deposition that he ever had any previous treatment for back pain and claimed he never sustained a previous back injury.

Zenith obtained medical records via subpoena that proved to be contrary to the claimant’s sworn testimony. The records reflected that the claimant had an extensive medical history dating back ten years from the date he alleged the claim with Zenith. These records revealed that the claimant was treated approximately 25 times at multiple locations, of which seven visits were to hospitals for back pain. The claimant’s prior treatment included x-rays and pain medication. The records also revealed that the claimant reported a fractured back from a previous injury.

The Result: The claimant was arrested, convicted, and sentenced to 18 months in state prison to be followed by probation and ordered to pay restitution in the amount of $28,000.