MARCH 25, 2003 - The 132nd District Court in Scurry County sentenced Jake V. Silva to two years imprisonment (probated to five years on probation) and 160 hours of community service after finding him guilty of fraudulently obtaining workers’ compensation benefits. The court also ordered him to pay:

• $1,000 in fines,
• $283 in court cost,
• $4,855 in restitution (payable at $110 per month), and
• $40 per month in probation fees.

Thanks to evidence gathered by Texas Mutual_SM investigator Tommy Jones and Texas Mutual_SM workers’ compensation specialist Danny Gentry, the prosecution was able to present a clear-cut case demonstrating that Silva deliberately committed fraud. Silva continued to collect temporary income benefits (TIBs) checks after he returned to work at a different company.

During the course of his claim, Silva received regular notices with each TIBs check reminding him that Texas Workers’ Compensation Commission Rule 129.3 requires injured workers to tell their insurance carrier if they return to work, earn wages, or receive an offer of employment. The prosecution presented the notices as evidence.

To prove fraud, however, the prosecution had to show that Silva knowingly lied in order to receive benefits. The prosecution’s strongest evidence was a recorded conversation between Gentry and Silva, in which Gentry informed Silva of his obligation to notify Texas Mutual Insurance Company if he began working while collecting TIBs.

The Silva investigation was part of the Texas Mutual_SM “Zero Tolerance of Fraud” program. Texas Mutual Insurance Company maintains three teams of investigators permanently assigned to investigate every report of suspected fraud.

MARCH 13, 2003 - The 90th Judicial District Court sentenced Eric Beaver to a two-year prison sentence after he pleaded guilty to fraudulently obtaining workers’ compensation benefits. Beaver must also pay a $1,000 fine, $253 in court costs, $300 for attorney fees, and $4,686.98 in restitution to Texas Mutual Insurance Company.

Beaver allegedly suffered an on-the-job injury while working for Orbit Plastic Pipe Inc. He started collecting temporary income benefits (TIBs) checks from Texas Mutual Insurance Company when his doctor declared that Beaver was unable to return to work because of the injury.

About two months later, he took a job as a handyman at Breckenridge Minit Mart, but hid the fact that he was working again so he could continue to collect TIBs. State law specifies that an injured worker must inform the insurance carrier if he or she returns to work in any capacity.

Texas Mutual_SM investigators presented the case to District Attorney Stephen Bristow. The Stephens County Grand Jury indicted Beaver on April 17, 2002.

Beaver received a credit of 253 days for the time he spent in the Stephens County Jail. Beaver will serve the remainder of his sentence in the Texas Department of Criminal Justice.

The Beaver investigation was part of the Texas Mutual_SM “Zero Tolerance for Fraud” policy. Texas Mutual Insurance Company maintains three teams of investigators permanently assigned to investigate every report of suspected fraud.

MARCH 3, 2003 - Houston truck driver Shirley Martinez pleaded guilty to workers’ compensation insurance fraud today. She received a five-year sentence under the Deferred Adjudication statutes, and the court ordered her to perform 300 hours of community service. The court also fined Martinez $500 and ordered her to pay $6,874.06 in restitution to Texas Mutual Insurance Company.

Martinez had claimed that she went to a local food bank every day because she couldn’t survive on her workers’ compensation benefits. A Travis County grand jury found that Martinez was receiving income benefits and earning wages by driving an 18-wheel truck for a vendor company.

State law requires injured workers to notify their carrier when they return to work. Not only did Martinez fail to notify Texas Mutual Insurance Company of her return to work, she also didn’t tell her previous employer, Chrismand Inc., that she had taken another job.

Texas Mutual Insurance Company began checking on Martinez after receiving a tip from a Chrismand supervisor, who noticed that Martinez was never home during the day. Texas Mutual Insurance Company initiated an investigation, which revealed that Martinez worked for the vendor company while still collecting income benefits. Investigators videotaped Martinez parking her personal vehicle at the food bank and departing in the vendor company’s truck. The tape also showed Martinez making daylong runs in the vendor company’s truck.

When Martinez took the job at the vendor company, she warned her new employer not to release any information about her or her employment. Texas Mutual Insurance Company took the case to Travis County prosecutor Jim Young, who issued subpoenas for the information. The evidence led to a grand jury indictment.

The Martinez investigation was part of the Texas Mutual_SM “Zero Tolerance for Fraud” program. Texas Mutual Insurance Company maintains three teams of investigators permanently assigned to investigate every report of suspected fraud.

FEBRUARY 13, 2003 - Armando M. Villesca Sr. of Fort Stockton pleaded guilty to charges of workers’ compensation insurance fraud. A Travis County District Court judge ordered Villesca to submit to three years of community supervision, perform 180 hours of community service, pay a $2,000 fine, and repay $2,965.30 in benefits he fraudulently obtained from Texas Mutual Insurance Company.

Villesca allegedly injured his right knee while working as a delivery driver for the Fort Stockton branch of Abtex Beverage Corporation. Villesca claimed that he was unable to return to work because his injury prevented him from climbing in and out of his delivery truck. Texas Mutual Insurance Company began paying temporary income benefits (TIBs) to Villesca.

Texas Mutual Insurance Company received information that Villesca was working as a contractor repairing homes and businesses while collecting TIBs for his alleged injury. Under state law, an injured worker who collects benefits must notify the insurance carrier if he or she returns to work in any capacity.

Texas Mutual_SM investigator Tommy Jones obtained statements, cancelled checks, and other documents that proved Villesca was working while collecting TIBs. In order to prove fraud, however, Texas Mutual Insurance Company had to show that Villesca knowingly collected benefits he was not entitled to.

Jones called Villesca and recorded a conversation in which the man denied working. Texas Mutual Insurance Company then presented the evidence to Assistant District Attorney James Young, who prosecuted the case.

Texas Mutual Insurance Company maintains three teams of investigators permanently assigned to investigate every report of suspected fraud. The investigation was part of the company’s Zero Tolerance for Fraud program.

FEBRUARY 5, 2003—The Amarillo Court of Appeals upheld a law preventing injured workers from collecting benefits for a work-related injury from two different sources. The court ruled that a Houston man who settled out of court with his employer over an on-the-job injury is not entitled to workers’ compensation benefits.

Glen Everett allegedly suffered injuries to his left arm and wrist while working for The Finished Touch, a general contracting company in Houston. Everett filed a negligence suit against The Finished Touch, but later dropped it and filed a claim for workers’ compensation benefits from Texas Mutual Insurance Company. Texas Mutual Insurance Company disputed the claim.

Before the parties could resolve the claim, Everett settled with The Finished Touch for $37,500.00. He later decided to re-file his claim for workers’ compensation benefits. Texas Mutual Insurance Company denied Everett’s claim, arguing that under the election of remedies law, he was not entitled to benefits because he received compensation for his injuries through the settlement.

The Texas Workers’ Compensation Commission (TWCC) disagreed, and ordered Texas Mutual Insurance Company to pay benefits to Everett. When the 127th District Court of Harris County reversed TWCC’s decision, Everett did not appeal, but TWCC did.

The Houston Court of Appeals’ caseload did not allow it to hear TWCC’s appeal, so it transferred the case to the Amarillo Court of Appeals, which ruled in favor of Texas Mutual Insurance Company. TWCC has filed for a rehearing.

JANUARY 17, 2003—Today, Texas Mutual Insurance Company announced its new Pharmacy Benefit Manager program. The program should help offset the rising costs of health care in the Texas workers’ compensation system, according to company officials.

Recent studies have shown that Texas’ workers’ compensation health care costs are among the highest in the nation. The Pharmacy Benefit Manager program is another example of how Texas Mutual_SM constantly explores new ways to help ensure cost-effective, high-quality care for injured workers. The program provides a wide range of pharmacies that can fill prescriptions for compensable injuries.

Texas Mutual_SM partnered with ScripNet to launch the program. ScripNet, which provides pharmacy managed care services exclusively to workers’ compensation insurance carriers, has a network of 2,400 pharmacies in Texas, and over 40,000 nationwide.