Tag: 2014 News

Wayne Lu, 53 of Torrance is in custody on charges of alleged workers’ compensation fraud associated with an injury received during his employment with the U.S. Postal Service. Detectives from the California Department of Insurance, with the assistance of U.S. Postal Inspectors, arrested Lu on Tuesday, April 8 in Manhattan Beach.

“Workers’ compensation fraud is not a victimless crime,” said Insurance Commissioner Dave Jones. “Fraudulent claims inflate premiums for all consumers and cast unnecessary doubt on workers that are truly injured and deserve timely treatment and rehabilitation.”

California Department of Insurance Detectives and United States Postal Service Office of Inspector General Special Agents conducted a joint investigation and learned that Lu was working as a massage therapist despite his claims of shoulder injury. Surveillance and undercover operations by Fraud Division Detectives proved that Lu was a working massage therapist and failed to report said employment or improvement of condition to the United States Department of Labor, the entity that handles workers’ compensation for the U.S. Postal Service.

Detectives from CDI’s Fraud Division are currently part of a task force operated by the Office of Inspector General – Postal Inspection Unit, focused on investigating and arresting postal employees who are suspected of committing insurance fraud in the State of California. Wayne Lu is charged with one felony count of insurance fraud and the case will be prosecuted by the Los Angeles County District Attorney’s Office.

On April 2, 2014, the Workers’ Compensation Appeals Board issued an en banc decision in Navarro v. City of Montebello which invalidated part of QME Regulation 35.5(e) .

In 2009, Ismael Navarro filed an application and claim form alleging a cumulative injury from February 9, 2008 to February 9, 2009 to his back and ear and was evaluated by panel QME J. Yogaratnam, M.D., Then in 2010, applicant filed applications for adjudication with claim forms alleging a specific injury of June 1, 2010 to his back, lower extremities and legs and a specific injury of August 31, 2010 to his back and left leg.

In 2012, defendant petitioned to compel an evaluation of applicant’s two subsequent claims of injury by original panel QME Dr. Yogaratnam, but it did not seek to have applicant reevaluated regarding his previous claim of cumulative injury. Applicant objected. The WCJ found that applicant was entitled to a new panel QME in his specific injury cases and that QME Rule 35.5(e) that seems to require an applicant to return to the original QME did not apply. The WCAB agreed (using a slightly different rationale) and ruled that for subsequently filed claims, an applicant need no return to an original PQME.

Pursuant to the WCAB’s ruling that the applicable Labor Code provisions do not require an employee to return to t he same panel QME for an evaluation of a subsequent claim of injury, the DWC Medical Unit will now issue new QME panels for claims made after an evaluation has taken place. Initial QME panel requests must be submitted using QME Form 106 for represented cases or QME Form 105 for unrepresented cases.

To avoid unnecessary rejection of appropriate requests, in cases i n which additional panels are required in different specialties, parties and attorneys are reminded to use QME Form 31.7

Crawford and Company today announced that it has appeared on this year’s InformationWeek Elite 100 – list of the top business technology innovators in the U.S. Crawford is being recognized by InformationWeek for a suite of innovative online and mobile tools that accelerate claims management;. The tools are accessed globally via an online portal called Crawford Desktop.

“We are honored to be recognized by InformationWeek for the sixth consecutive year for our creative development of very effective technology,’ said Brian Flynn, Crawford executive vice president and global chief information officer. ‘Crawford Desktop is a robust, flexible platform and its numerous features contribute directly and measurably to increasing claim processing efficiency.”

Crawford Desktop uses mobile device geo-location to pinpoint the closest most qualified adjuster for a given claim site and claim type. The assignment is then electronically delivered to a qualified adjuster based on location, availability and performance scorecard. The adjuster accepts the assignment, travels to the site and documents each step of the claims management process (including uploading video, images and voice notes) to the Crawford Desktop portal from a mobile device.

The portal may accessed from a variety of mobile devices, including iPads®, iPhones®, BlackBerry® or Android® phones, with the adjuster’s data transferring to Crawford’s claims management system. Another unique feature of Crawford Desktop is the integration of social media into the claims management process, which provides collaboration with clients and Crawford employees, allowing adjusters in the field to solve problems interactively and in real-time.

This is InformationWeek’s 26th year identifying and honoring the nation’s most innovative users of information technology. For 2014, this assessment was narrowed to a more elite 100 organizations. InformationWeek’s Elite 100 research tracks the technology-based investments, strategies, and results of some of the best-known organizations in the country. Unique among corporate rankings, the InformationWeek Elite 100 spotlights the power of business technology innovation. Additional details on the InformationWeek Elite 100 can be found online at the InformationWeek Website.

A San Francisco Municipal Transportation Agency bus driver was charged Monday with allegedly lying about being injured in a 2012 robbery – an attack that authorities said never happened.

The report in SFGate says that Velma Louise Jones, 61, of Vallejo told San Francisco police she was robbed while working a shift on June 1, 2012, prosecutors said. She filed a workers’ compensation claim, saying she suffered head injuries.

But prosecutors said surveillance video from her bus contradicted her story. While three books of transfer tickets were stolen that day, Jones was allegedly taking a break away from the bus during the theft. The San Francisco district attorney’s office said it began investigating the case after being contacted in August by the insurance company dealing with the workers’ compensation claim.

Jones was charged with four felonies: workers’ compensation fraud, filing a fraudulent insurance claim, submitting documents in support of a fraudulent insurance claim and making false statements in connection with an insurance claim. District Attorney George Gascón described Jones as a city employee who “attempted to take a paid vacation from work at the expense of San Francisco taxpayers.”

Daniel Siegel, her attorney, said the case was a misunderstanding. Though Jones was not on the bus at the time of the attack, he said, she was outside it and the man who stole her transfers had shoved her out of the way, knocking her head against the bus. She withdrew her claim, Siegel said, when she “decided it wasn’t that big of a deal.”

Jones, released on $50,000 bail, appeared in court Monday. If convicted, she faces a maximum of eight years in state prison or county jail. She is on paid leave, according to the Municipal Transportation Agency.

Jeffrey Fujimoto claimed that he suffered a continuous trauma psychiatric injury while employed as a body technician for Caliber Collision Centers. The parties agreed to use Myron L. Nathan, M.D., as the AME in this case. Dr. Nathan attributed 90% apportionment of the causation of the Applicant’s psychological injury to work-related stress. After a hearing in the case, the WCJ instructed the parties to obtain a definitive report from the AME, regarding factors of causation pursuant to [Rolda v. Pitney Bowes. Inc. (2001) 66 Cal. Comp.Cases 241, 247 (Appeals Board en banc)].”

Specifically the WCJ instructed Dr. Nathan as follows. “[P]lease provide a supplemental report that describes in detail, in accordance with Rolda, all the workplace and all the non-industrial related events and/or issues that combined caused the Applicant’s psychological injury. You are then to assign a percentage of causation separately to each individual work-related and/or non-industrial event(s) and/or issue(s) that, when combined, equal 100% of the causation of the Applicant’s psychological injury. You are not to combine percentages as to any multiple factors and/or issues, either industrial or non-industrial.

It will ultimately be up to me to decide which workplace activities are actual events (i.e., which of the event(s) described by the Applicant happened or not) and whether those events that I have deemed to be actual events are otherwise legitimate, non-discriminatory, good faith personnel actions. Based on this, I can determine if the actual events of employment, if added together, will result in them being the predominant cause (i.e., more than 50%) of the Applicant’s psychological injury and, whether those actual causes were substantially caused (i.e., 35% to 40%) by lawful, nondiscriminatory, good faith personnel actions.” The instruction provided the format for the AME to list and number each industrial and non-industrial event and assign a separate percentage of causation to each numbered event.

In response to the WCJ’s correspondence Dr. Nathan provided a list of 13 separately listed stressful events, and the percentage of causation of each event. After reviewing the evidence, and the 13 item list. the WCJ found that only item number 4 pertaining to a graffiti incident was an “actual event of employment” and this item caused 4% of the psychiatric injury according to the opinion of Dr Nathan. The WCJ issued his Findings of Fact and Order and Opinion on Decision finding that, in accordance with Labor Code § 3208.3(b)(1) and Rolda, that the Applicant did not sustain industrial injury to his psychological system.

The applicant’s Petition for Reconsideration was denied in the panel decision of Jeffrey Fujimoto v Caliber Collision Centers; Hartford Accident and Indemnity Company.

A WCJ is not compelled to blindly accept the testimony of any witness deemed to be untruthful given that he or she is the ultimate finder of fact and is entitled to make his or her own credibility determinations. [Garza v. Workmen’s Comp. Appeals Bd. (1970) 35 Cal. Comp. Cases 500, 505] While the WCAB may reject the findings of a WCJ and enter its own findings on the basis of its review of the record, [Labor Code § 5907] when a WCJ’s findings are supported by solid, credible evidence, they are to be accorded great weight and should be rejected only on the basis of contrary evidence of considerable substantiality. [Lamb v. Workers’ Comp. Appeals Bd. (1974) 39 Cal. Comp. Cases 310, 314]

The multilevel analysis to establish compensability for claims of injury based on personnel actions, in accordance with Rolda v. Pitney Bowes. Inc. (2001) 66 Cal. Comp. Cases 241, 247 (en banc), is as follows:
(1) whether the alleged psychological injury involves actual events of employment, a factual/legal determination;
(2) if so, whether such actual events were the predominant cause (i.e., accounting for 51% or more) of the psychological injury, a determination which requires medical evidence;
(3) if so, whether any of the actual employment events were personnel actions that were lawful, nondiscriminatory and in good faith, a factual/legal determination; and
(4) if so, whether the lawful, nondiscriminatory, good faith personnel action were a “substantial cause” (i.e., accounting for at least 35% to 40%) of the psychological injury, a determination which requires medical evidence.

Having reviewed all of Dr. Nathan’s reports and considering the Applicant’s lack of credibility in his testimony, the WCJ could not conclude that any of the Applicant’s claimed employer actions, except the graffiti were ‘actual events.’