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The Los Angeles County district attorney's office has for nearly a decade operated with a built-in potential for a
conflict of interest stemming from its acceptance of private money to pay for public prosecutions of workers' compensation
insurance fraud.
When defense lawyers challenged this use of private funds, which was authorized by the state Legislature, prosecutors said
not to worry: Their judgments were independent. Appellate courts agreed with prosecutors that there was no actual conflict
of interest.
However, a review of prosecutors' performance shows that their decisions--on whom to investigate and on whom to
prosecute--have consistently favored those who provide them with money.
The money originates with the state's employers and is handed out by employers and insurers. It is supposed to combat
workers' compensation fraud in all its forms--whether committed by employers, insurance companies or workers.
But the district attorney's office has downplayed employer fraud and repeatedly ignored evidence of possible crimes by
insurance companies. At the same time, it has cracked down hard--and sometimes unjustly--on the workers whom insurance
companies and employers accuse of lying about on-the-job injuries.
A case in point is that of Indravadan Jayaswal.
Jayaswal was experiencing classic symptoms, one of his doctors said, of a "clerical workers' sickness" caused by the
repetitive stress of spending all workday, every workday, typing on a computer. He was, therefore, his doctor said,
entitled to workers' compensation benefits.
But Jayaswal had not at first claimed that his ailments were work-related. He said he was afraid he would be fired if he
claimed to have been injured on the job. So, when pressed, he said he told his doctors initially that he had experienced
pain lifting his garage door.
An insurance adjuster seized on the garage door statement as evidence that Jayaswal was lying when he later attributed his
injuries to work. Without asking him to explain, prosecutors charged him with the felony of lying to collect benefits.
Compare that to the way prosecutors handled what they regarded as lies under oath by some of their benefactors.
District attorney officials said they collected evidence that seven insurance company executives had perjured themselves
in reports to state regulators. The executives overstated the extent to which their companies were financing their own
legally required efforts to ferret out fraud. The district attorney's office was almost wholly dependent on these efforts
as the source of its workers' compensation fraud cases.
Although the head of the D.A.'s anti-fraud effort routinely prosecuted workers for lying under oath, he said it did not
occur to him to apply the same standard to the insurance executives. He did not see them as his targets. Nor did his
office. The extent to which prosecutors had abandoned even the possibility of going after insurers was made clear in a
1998 job advertisement for the workers' compensation anti-fraud unit. "The suspects we investigate," said the ad, issued by
Chief Deputy Dist. Atty. Robert P. Heflin, "include workers, employers, doctors and lawyers." The ad did not even mention
the possibility that insurance companies could be charged with crimes.
The unit's priorities are evident at a glance:
Good Intentions
That wasn't enough for some doctors and lawyers, who paid recruiters to troll unemployment insurance lines, telling
laid-off workers that they would be better off if they claimed that they had been injured on the job. Insurance companies
rarely challenged these fraudulent claims, electing instead to pay them and pass the costs along to their
employer-customers. These activities caused a genuine fraud crisis in Southern California in the late 1980s and early
1990s, resulting in steadily increasing insurance premiums for businesses already struggling in a recession.
Employers organized and got the attention of state legislators by screaming that they couldn't afford to pay these higher
premiums and threatening to leave California if something wasn't done. Then-state Sen. Robert Presley (D-Riverside) took
the lead in writing legislation aimed at putting the unscrupulous doctors and lawyers out of business and behind bars.
Workers were never the target, said James Morris, an aide to Presley. "Everyone realized that the workers in this context
were kind of the sheep in this whole thing," he said. Presley's legislation, which passed in 1991, was unusual in that it
required employers, rather than taxpayers in general, to pay for investigations and prosecutions through a surcharge
collected on their insurance premiums.
There were two reasons Presley took the private money approach. The state was in the red and Presley said any general fund
appropriation would not pass. County prosecutors were unwilling to use tax money already assigned to them. They had higher
priorities; violent crimes. Morris, the Presley aide, recalled speaking to several county prosecutors, including
representatives of the Los Angeles County district attorney's office who told him: "Unless we see any money, we're not
going to be prosecuting this type of case."
Employers are now assessed a statewide total of $30 million a year. In the Legislature's scheme, the money is divided
between the state Department of Insurance for investigations and the various county district attorney's offices.
Prosecutors apply for the money annually to the insurance commissioner, who doles it out with the consent of the state's
Fraud Assessment Commission, which consists of two insurers, two self-insured employers and one otherwise insured employer.
The Los Angeles County district attorney's office has historically gotten the lion's share of the funds.
The private dollars paid for a slew of prosecutions, proving, said Stanley Zax, chief executive of Zenith Insurance Co.,
that district attorneys are like anybody else: "When they are incentivized to go after something, they go after it."
Medical Mills
The district attorney's office won only one of its big mill cases, against a psychiatrist named Mark Kaplan, whose frauds
were also documented by television news people operating undercover. The office lost the other three such cases it pressed
to conclusion. Part of this was because prosecutors ineffectively presented evidence, jurors and defense lawyers said.
Part was because jurors had trouble distinguishing between fraudulent actions and actions that were lawful--just greedy.
The operators of a large chain of clinics who were accused of systematically overcharging insurers and performing
unnecessary tests offered lawful greed as their defense. "They charged the absolute maximum that was available under the
law," said defense lawyer Michael Chaney. "Charging too much isn't fraud. It's just excessive." Jurors agreed.
The second in command of the district attorney's workers' compensation unit also agreed. Deputy Dist. Atty. Richard
Rosenthal advocated abandoning his own prosecution of another large string of clinics called Primedex. He concluded that
its alleged insurance company victims were not really victims; they were more like accomplices in that they had willingly
paid Primedex's bills and passed the costs along to employers.
"It is obvious that Primedex exploited the workers' compensation system," Rosenthal wrote to his superiors in a
confidential memo. "It is obvious that Primedex ordered medically unnecessary procedures. But it is also obvious that the
insurance companies and [state workers' compensation judges] allowed the acts to occur." They all participated in what
amounted to "a giant quasi-legal Ponzi scheme with citizens of this state on the losing end," he said. Rosenthal declined
to comment for this story.
Although he repeatedly recommended giving up on Primedex, his superiors would not allow it. The district attorney's office
had spent millions in private funds on the mammoth prosecution and had repeatedly promised the Fraud Assessment Commission
that arrests were imminent. Five years after Rosenthal recommended dumping the case, former Primedex executives are still
awaiting trial. The prosecutor who inherited the case, Deputy Dist. Atty. Robert Foltz, thinks it is going to be a tough
sell.
"The amount of provable fraud in the case is really in question," he said in an interview, "because basically the law
allowed what they were doing." Primedex itself went out of business long ago, as did many of the clinics specializing in
workers' compensation cases. They folded, in some cases, because they were spooked when the district attorney's office
obtained search warrants to seize their files and, in other cases, because the Legislature clamped down on the billing
excesses that had made the clinics so profitable. The Legislature imposed a schedule that limited fees for the first time
in 1993.
The medical mill prosecutions saved insurance companies millions of dollars. Primedex alone claimed that it was owed $159
million for medical services when it shut down. Under ordinary circumstances, the company's internal memos say, it could
have expected to collect $135 million. Once the district attorney's office alleged fraud, however, insurance companies
were able to settle for less than $10 million.
See No Evil
In a letter to lawyers for some of the doctors, the executive, Hy Bates, said he attended a secret meeting in 1991 with
representatives from three dozen other insurers active in the Los Angeles area. "The gist of the strategy," he said, "was
to target the [medical] facilities with the highest dollar volumes . . . and then utilize any technical or legal argument
available to them to deny or delay payment."
Deputy Dist. Atty. Edward Feldman, who headed the workers' compensation fraud unit from its inception in 1992 until the
end of 1996, said he was skeptical about the lawsuits because he suspected that some of the doctors were crooks. He said
he had never heard about the secret meeting Bates described. The district attorney's office also did not investigate the
finding of a civil jury in Los Angeles Superior Court, which concluded that the state's largest workers' compensation
insurer defrauded an employer of hundreds of thousands of dollars.
The insurer, the quasi-public State Compensation Insurance Fund, tricked its prospective customers, jurors concluded. Its'
sales force told employers that their premiums would be based on a realistic assessment of what claims by injured workers
would cost, jurors found, but instead the premiums were based on the highest possible cost. Court of Appeal justices
upheld the jury verdict of civil fraud and ordered the insurer to pay a $5-million punitive damage award, asserting:
"There was substantial evidence that senior management personnel at SCIF . . . intentionally misled prospective insureds."
For the district attorney's office, prosecuting the State Compensation Insurance Fund would have meant biting the hand
that fed it--in more ways than one. The fund's president is a permanent member of the Fraud Assessment Commission, which
decides how big a chunk of the anti-fraud funds the Los Angeles County district attorney's office gets each year. The
fund, prosecutors say, is also the most cooperative insurance company in providing information that leads to cases.
Feldman said that had nothing to do with the decision not to go ahead with a criminal probe. He said that the fund's
misconduct was called to his attention but that he had higher priorities, particularly since his efforts would be
duplicative: A civil jury had already punished the insurer. That, Feldman suggested, seemed punishment enough.
Hear No Evil
Young's estimate did not include additional sums that insurers saved by not notifying workers when they were eligible for
vocational rehabilitation benefits, as required by law. The same audits showed that, year after year, insurers failed to
inform nearly half of all injured workers who had been out of work for 90 days that they were eligible for job retraining.
Cora Lee, who is in charge of the audits for Southern California, once testified in a deposition that up to 80% of the
files checked at some insurance companies have showed money owed. "We've had some really nasty companies," she said.
Officials in the Los Angeles County district attorney's office, including Feldman and the current head of the workers'
compensation fraud unit, Deputy Dist. Atty. Philip Wynn, acknowledged that a criminal investigation might be appropriate
to determine whether these patterns of shortchanging workers were intentional.
But these same officials and their supervisor, Director of Special Operations Allen Field, said they had never launched
one because they had never heard of the audits, which were mandated by the Legislature in 1989 and have been the subject
of legislative hearings, news releases and trade press reports. Summaries of the 150 audits conducted to date are
available on the Internet at http://www.dir.ca.gov/dwc/audit.html.
Not everyone in the office was in the dark. Kristie Hutchinson, then and now the unit's special assistant, said she knew
about the state auditors, though not about the audit results. David Guthman, who headed the unit for one year in 1997,
said he learned about the audits when the Division of Workers' Compensation approached him for help during one particular
audit, of the Fremont Compensation Insurance Group of Glendale. Fremont marketed itself as a company that could save
employers money by rooting out worker and doctor fraud. It advertised on more than 600 billboards around the state that
showed cheating workers behind bars. Its slogan was "Fraud Doesn't Work Here."It was wrong about that.
Auditors alleged that Fremont employees, spread among all three of its California claims-adjusting locations--Glendale,
Fresno and San Francisco--backdated about 10,000 documents between 1990 and 1996. Auditors alleged that the backdating,
which sometimes saved Fremont late-payment fees to workers and doctors, was sufficiently widespread as to constitute a
general business practice.
To settle an administrative case that could have cost it its license, Fremont agreed to pay $525,000 without admitting
wrongdoing and promised to spend an additional $200,000 to train employees to play by the rules. It also agreed to change
its computer system to make backdating impossible. Fremont said settling the case was cheaper than fighting it. Fremont
reported six of its employees to prosecutors. Two from its Fresno office were convicted of fraud-related charges. Four
from its San Francisco office were never charged. Jacqueline Schauer, the lawyer for the auditors, ridiculed the extent of
Fremont's housecleaning, saying that apparently more than 150 Fremont employees in the San Francisco office alone were
involved. Fremont did not refer any of its Glendale headquarters employees to the Los Angeles County district attorney's
office.
While investigating the backdating allegations in Glendale, however, auditors had approached the district attorney's
office for help. The auditors said through a spokesman that they wanted the district attorney's office to grant immunity
to some Glendale employees so they could question them. But they said the district attorney's office declined.
Dist. Atty. Adalbert Botello, the supervisor who was the primary person dealing with the auditors, said he thought they
merely wanted legal advice on immunity procedures, which he gave. He said he did not see their inquiry as a reason to
assign his unit's investigators to probe for possible criminal acts by Fremont or its employees.
Employer Fraud
Deputy Dist. Atty. Barry Gale--the only one of the unit's 16 prosecutors who handles employer fraud--said he has been
frustrated because he has been unable to get insurance companies or others to refer him cases. Only eight of the state's
approximately 300 workers' compensation insurers have done so, he said. Gale said he tried to open an investigation into
employers who illegally operate without insurance. Taxpayers pay more than $20 million a year in benefits to injured
workers whose employers don't have insurance. But the state Insurance Department blocked him with a legal opinion. Its
conclusion: Private industry pays his salary to prosecute insurance fraud, and people who do not have insurance, by
definition, cannot commit that crime.
Some of the state's large employers qualify to insure themselves. They have the same responsibility to handle claims
fairly as insurance companies, and the same auditors who check insurance companies also review their practices and
sometimes find them wanting. Ralphs Grocery Co. of Los Angeles set a new record in 1998 for "amount in penalties in one
audit." The total: $217,530. Ralphs had shortchanged about half of 154 injured workers whose claim files were checked--by
a total of $106,000. Auditors also found that Ralphs failed to investigate some claims and denied benefits in others
without saying why. Ralphs did not respond to an invitation to
comment.
District attorney officials never looked into these allegations to determine whether the short-changing was intentional.
They said they learned of the Ralphs audit for the first time while being interviewed for this article.
'Low-Hanging Fruit'
In its most recent grant application, the Los Angeles County district attorney's office said the workers it goes after
commit outrageous fraud: "supposedly bed-ridden claimants [who are] playing tackle football." It produced records of two
cases it said were typical. One involved a $5-an-hour temporary laborer who hurt his heel but exaggerated his injury and
was caught on videotape rehearsing a limp with a cane in a doctor's parking lot. The other involved a bartender who said
he hurt his back on the job; he was collecting disability while secretly working as a bartender elsewhere. Those records
did not provide a full picture.
The district attorney's office also picks off people such as:
The district attorney's office had Solis arrested. Agents carted him off during an early morning raid on his Huntington
Park house as his 80-year-old mother screamed: "You can't take my son. My son is no thief!" Atty. Eleanor Daniels did not
dispute that Solis had been injured. She told Los Angeles Municipal Judge Elva Soper that he was arrested for exaggerating:
"The impairment is not as extensive as 100% disabled." Soper made her own observations and took an unusual step early in
the case. She appointed a specialist on the mental effects of brain injuries to examine Solis for the defense at public
expense. Dr. Robert Brook looked at the secretly recorded videotapes and concluded that they proved Solis was gravely
disabled. An average adult takes far less than a minute to tie his shoelaces, he said. A videotape showed that Solis took
three minutes. Another tape showed that when Solis was playing flag football, he seemed to be playing by himself, Brook
said. Neither his teammates nor his opponents paid him any mind. Still another tape showed that in a race-walk, he
couldn't master the fundamental stride, the doctor said. He was disqualified.
"It was a rather sad vignette," Dr. Brook testified. He said the only kind of work Solis could do would involve "simple,
concrete, repetitive activities under constant supervision." Over the D.A.'s objections, Soper dismissed the case. She
also dismissed a companion case against Solis' brother Austin, who had been accused of fraud for allegedly lying to
doctors about his brother's limitations.
*Edgar Huaz
The D.A.'s office agreed and charged Huaz with insurance fraud. But its case fell apart when Dr. Deere testified that it
would have been a physical impossibility for the fight to cause the injury he saw when he opened Huaz's head. The district
attorney's office dismissed the case.
*Indravadan Jayaswal
When Jayaswal returned to work with restrictions on using a computer, records show, a supervisor referred him to Blue
Cross' health and safety department. He then filled out a workers' compensation claim, stating that his pains were
work-related. A claims examiner for Blue Cross' Workers' Compensation insurance carrier, a Kemper company, became
suspicious. When an insurance company-hired doctor told the claims examiner that she was on to something, Kemper
referred the case for investigation and prosecution to the state Department of Insurance and to the district attorney's
office. In doing so, Kemper officials said Jayaswal was known to file false claims--an assertion they later admitted they
could not support, according to court records. They also suggested that he fraudulently filed for workers' compensation
benefits to pay for his medical care because he had no group health insurance. In fact, he had used his group health plan
to pay for his treatments.
The Department of Insurance investigation into whether Jayaswal's injuries were related to his job was woefully incomplete.
"What is his job?" the case investigator was asked at a preliminary hearing. "I really don't know," he said. He told a
judge, however, that he had spoken to the specialists who had treated Jayaswal initially and that both had told him that
Jayaswal's ailments could have been caused by his job. At Jayaswal's trial one of the same doctors went further. He
testified that, not only could Jayaswal's problems have been work-related, they probably were. The prosecutor said this
did not matter. Deputy Dist. Atty. Robert Wallace argued that fraud hinges on a state of mind. He contended in court that
whether Jayaswal was entitled to benefits or not was irrelevant. If he merely tried to collect benefits while believing
that he was not entitled to them, that would be enough for a conviction.
Superior Court Judge Michael Tynan did not need to hear any more. He acquitted Jayaswal before the defense put on any
witnesses. Jayaswal sued the insurance company for malicious prosecution and settled with Kemper for an undisclosed sum.
But he could not get his old job back. He said he could not even get a job in the same industry. "They destroyed all my
life," said Jayaswal, now 61. "I was just interested in why I had pain. I had a good job. My company was paying a lot of
overtime. . . . Why should I go to workers' compensation? I wasn't going to get [much money]. I only wanted the pain to go
away."
System Defended
Insurance companies don't pay the bills, the district attorney's office points out. They merely have a say in how the
funds are handed out. The district attorney's office says it is insulated from influence by individual employers since all
employers are obligated to pay a surcharge on their insurance premiums--whether they like it or not.
Trial and appellate courts have reviewed these funding arrangements and have agreed with the district attorney's office
that no conflict of interest exists. District attorney's officials added that they would gladly look into allegations that
insurers were ripping off workers if someone would just bring them the evidence. The officials said they have repeatedly
asked, in vain, that lawyers who represent injured workers seeking benefits bring them cases of suspected criminal
wrongdoing by insurers or employers. Prosecutors said their appeals for cooperation have been made at functions put by on
by these workers' lawyers, who are known as applicants' attorneys.
There are three applicants' attorney groups in Los Angeles County. A member of one said he had a client who contacted the
district attorney's office and found officials receptive to looking into a complaint about possible insurer fraud. No
action has been taken in that case. But presidents of the other two applicants' attorneys associations said they were
dumbfounded by the district attorney's office assertion that it had tried to get them to refer cases. "I must live on a
different planet," said Larry Stern, president of the Southern California Applicant Attorneys Assn. "Applicant attorneys
have given up writing to the D.A.'s office, because they don't respond. . . . It's a waste of 33 cents."
Conflict of Interest
As Feldman struggled to keep the district attorney's workers' compensation unit going with "two hands . . . tied behind
our back," his special assistant called to his attention evidence that executives of some of the precious few firms that
were cooperating had committed perjury. The special assistant, Hutchinson, said the executives had made "material
misrepresentations" under oath, overstating the extent of their anti-fraud efforts in reports to state regulators.
Feldman acknowledged that filing perjury charges against them would have been possible--even that it would have had "nice
symmetry" given his unit's custom of charging alleged worker cheats with perjury. But he said that arresting the
executives never crossed his mind. Pressed to explain, he said that even if it had occurred to him to prosecute, it
would have been counterproductive. The insurance carriers involved were among the few that were bringing any cases to the
unit. If he had filed charges, Feldman said, they would have stopped. And if that happened, he added: "We'd have to close
down our shop." |