DECEMBER 23, 2002—After a woman’s car rear-ended a trash trailer on the side of the road in Houston, an ambulance arrived on the scene to find Ronald J. Dawson sprawled nearby in the grass. He claimed that the trailer had knocked him some 20 feet away when the woman’s car rear-ended it.
Dawson had been employed with On Our Own Services Inc. in Houston picking up trash bags on the side of the road. He filed for workers’ compensation benefits for an alleged injured knee, and Texas Mutual Insurance Company began paying on the claim.
Eight months later, On Our Own Services owner Shawn Quigley complained to a Texas MutualSM claim adjuster that Dawson was trying to “drag out the claim” to get more money from a pending third-party lawsuit. The adjuster referred the case to the special investigation department.
Eileen Cook, a Texas MutualSM fraud investigator, contacted Quigley and discovered that Dawson’s co-worker had reported the incident to the company’s safety director, who had taken photos of the accident scene. The photos clearly showed that the car pushed the trailer straight into the back of the van that was towing it, not to the side. Therefore, the trailer could not have struck Dawson as he had claimed.
Cook continued her investigation and obtained a statement from Dawson’s co-worker, the driver of the van, stating that the trailer did not touch Dawson. According to the co-worker, Dawson walked to a grassy area, smoked a cigarette, and laid down to wait for the ambulance. When the ambulance arrived, Dawson told the co-worker that the next time they met, he would be driving a Cadillac.
Dawson later sued the woman for the alleged injury to his knee.
Cook discovered that Dawson’s knee injury was inconsistent with damage resulting from a collision. In fact, the medical x-rays showed Dawson’s knee to be full of shotgun pellets. Further investigation revealed that Dawson, a two-time convicted felon, had received regular treatment for the shotgun pellets in his knee during his first prison sentence.
Based on Cook’s investigation, a Travis County Grand Jury indicted Dawson. Assistant District Attorney Donna Crosby prosecuted the case and reached a plea-bargain agreement with Dawson.
Texas Mutual Insurance Company maintains three teams of investigators permanently assigned to investigate every report of suspected fraud. The Dawson investigation is part of the company’s Zero Tolerance for Fraud program.
Texas
Mutual Scholarships Provide
Additional Legacy to Survivors
NOVEMBER 30, 2002—For the 2002-2003 academic year, Texas Mutual Insurance Company awarded six scholarships totaling $18,478 to family members of individuals who died from work-related accidents. Since the program’s inception last year, Texas Mutual Insurance Company has awarded 13 scholarships worth over $34,879.
"As a company, our goals are not only to reduce the number of work-related injuries and illnesses in Texas, but also to minimize their consequences," said President Russ Oliver. "In the case of a work-related fatality, we hope that a scholarship might serve as part of the deceased employee’s legacy to his or her family, thereby reducing the family’s financial burden."
Acting on Oliver’s recommendation, the board of directors unanimously approved the scholarship program last year. The program is open to unmarried spouses or children of an individual who died from a compensable injury while working for a Texas MutualSM policyholder. Selected individuals may receive up to $2,000 per semester.
Oliver noted that the company may consider several factors before offering a scholarship, including the individual’s economic need, standardized test scores, and high school or college academic performance, as applicable. Additionally, the recipient must maintain at least a 2.75 or equivalent grade point average for the duration of his or her scholarship.
The Texas MutualSM scholarship program is not an automatic benefit, and the decision to offer a scholarship rests solely with Texas Mutual Insurance Company. The company reserves the right to alter or discontinue the program at any time without notice.
For more information about the Texas MutualSM scholarship program, click here or write to Texas Mutual Insurance Company, Office of the President, 6210 East Highway 290, Austin, Texas 78723-1098 .
NOVEMBER 7, 2002—The Scurry County Grand Jury indicted Jake V. Silva on charges of fraudulently obtaining workers’ compensation benefits. A Texas MutualSM investigation revealed that Silva continued to work while collecting temporary income benefits (TIBs) for an alleged on-the-job injury.
Silva allegedly suffered an injury to his right arm while working for B&F Well Service in Snyder. The same day, a doctor cleared him to return to work with restrictions. When B&F was unable to meet those restrictions, Texas Mutual Insurance Company began paying TIBs.
The Texas MutualSM adjustor handling the claim got suspicious because Silva was difficult to contact while off work. The investigation revealed that shortly after leaving B&F, Silva started working for Midwestern Services Company, Inc. in Snyder. He later worked for Express Personnel, a staffing service in Midland, where his assignments included operating windmills. After leaving Express Personnel, Silva accepted a job with Teraco, Inc. in Midland. Texas law states that an injured worker who is collecting TIBs must notify the insurance carrier if he or she returns to work in any capacity.
“Our adjustors are trained to recognize the warning signs of fraud,” said Elliott Flood, VP of Special Investigations at Texas Mutual Insurance Company. “When an injured worker is difficult to contact, or is belligerent when contacted, it raises our suspicion. Many of our fraud investigations start when an adjustor feels that too many things about a claim just don’t add up.”
To prove fraud, the Texas MutualSM investigator had to show that Silva knowingly lied in order to receive benefits. The evidence included a recorded conversation between the Texas MutualSM adjustor and Silva, in which the adjustor informed Silva of his obligation to notify Texas Mutual Insurance Company if he began working while collecting TIBs. Silva had also received written notices with his TIBs checks and with form TWCC-26 (Texas Workers’ Compensation Commission).
Note: A grand jury indictment is a formal accusation--not a conviction--of criminal conduct.
OCTOBER 11, 2002—A Travis County Grand Jury indicted Stan and Cynthia Doze yesterday on a second-degree felony charge related to workers’ compensation premium fraud. The Dozes own Doze Construction Company Inc. in Gun Barrel City, about 60 miles southeast of Dallas.
Allegedly, the Dozes transferred part of their company’s payroll into a second company in an attempt to evade paying the legitimate insurance premium. Doze Construction then applied to Texas Mutual Insurance Company for workers’ compensation insurance, but it reported only a fraction of its true payroll. Because workers’ compensation insurance premium is based in part on payroll, the scheme allowed Doze Construction to be charged much less than it actually owed.
“Anytime a policyholder falsely reports its payroll, classification codes, or experience modifier to avoid paying the legitimate premium, that’s fraud,” said Elliot Flood, vice president of Texas Mutual’s Special Investigations Department. “Premium fraud is a serious crime. It’s bad for honest competition in the marketplace, and it is bad for the fraudulent company’s workers, who are entitled to the benefits of workers’ compensation, a fact often hidden from them by the dishonest employer.”
Note: A grand jury indictment is a formal accusation--not a conviction--of criminal conduct.