Published in Adobe pdf format effective August 1, 2016

Transcription

Zalma’s Insurance
Fraud Letter
The Essential Resource For The Insurance Fraud Professional
A ClaimSchool ™ Publication, Written by Barry Zalma, Esq., CFE
© 2016 ClaimSchool, Inc. & Barry Zalma
Volume 20, No. 15
August 1, 2016
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Quote of the Issue
“We must always take sides. Neutrality helps the oppressor, never the victim. Silence
encourages the tormentor, never the tormented.”
Elie Wiesel (RIP)
State Fraud Investigation Files Not Subject to Discovery by Subpoena
In Gurvey v. Montclair Township, 2016 WL 3387202, 2016 WL 3387202 (N.J.Tax) a New Jersey appellate court was faced with an
attempt by an insurance claimant, not charged with any crime, to receive information contained in the files of the
state fraud investigation agency concerning a claim the Gurveys presented to their insurer who, in accordance with
state law, reported a suspicion of fraud.
Factual Findings and Procedural History
On or about April 7, 2010, the DOBI Consumer Protection Services unit opened an investigative file in response to
a consumer complaint filed by plaintiffs, H. Scott Gurvey and Amy Gurvey (“plaintiffs”). Plaintiffs consumer
complaint arose from an insurance claim involving damage to plaintiffs’ residence located at 315 Highland
Avenue, Upper Montclair, New Jersey (the “subject property”).
On or about September 20, 2010, the DOBI Consumer Protection Services unit closed its investigative file without
pursuing any formal disciplinary action. In accordance with the DOBI’s Records Retention and Disposition
Schedule, Agency S580800, Schedule 003, the DOBI Consumer Protection Services unit investigative file was
maintained for a period of three years after it was closed and then destroyed.
On or about October 27, 2015, the DOBI’s Bureau of Fraud Deterrence opened an investigative file, for the purpose of conducting “an
insurance-fraud investigation” with respect to plaintiffs’ insurance claims and the subject property.
On or about April 5, 2016, plaintiffs sent, by regular mail, a Subpoena Duces Tecum and Ad Testificandum (the
“Subpoena”) addressed to Matthew Noumoff, OPRA Custodian for the DOBI.1 The Subpoena was received on April 8,
2016 and was returnable April 22, 2016. The Subpoena seeks the following:
1.
The entire file or files (including any electronically stored information) maintained by the DOBI relating to the
Gurveys and/or the property. This includes but is not limited to, the following:
a.
All reports concerning the property;
b.
All correspondence (including emails) with the Gurveys;
c.
All documents (including emails) exchanged with the Gurveys;
d.
All correspondence (including emails) and/or other documents with any other person or entity relating
to the Property or the Gurveys;
e.
All photographs of the Property;
f.
All other documents that depict, describe, evaluate, or otherwise relate to the
condition of the Property;
g.
All documents (including emails or notes) reflecting the DOBI’s internal
communications with the Gurveys or about the Gurveys;
h.
All documents (including emails or notes) exchanged with State Farm concerning
the Gurveys and/or concerning the Property;
Zalma's Insurance Fraud Letter -- Page 1 of 22
2.
i.
All documents (including emails or notes) reflecting the DOBI’s internal communications with State
Farm about the Gurveys;
j.
Any notes written, dictated or otherwise recorded by DOBI employees reflecting its investigation,
evaluation or research into the condition of the Property or otherwise pertaining to the Property, and
k.
evaluation or research into processing by State Farm of any insurance claim filed by the Gurveys;
l.
evaluation or research into any complaint against State Farm filed with DOBI by the Gurveys.
To the extent not included in response to the previous requests, any all correspondent, emails, contracts,
photographs, notes, reports, etc., relating to the Property of the Gurveys.
In response to plaintiffs’ Subpoena, on April 22, 2016, the DOBI filed with the court a motion to quash the
Subpoena arguing that the documentation and information sought by the Subpoena from the DOBI’s Bureau
of Fraud Deterrence are specifically shielded from disclosure under N.J.S.A. 17:33A–11, and under the
corresponding administrative regulations codified in N.J.A.C. 11:16–6.11.
Plaintiffs argue that because Gale Simon, Assistant Commissioner of the DOBI Consumer Protection Services
unit, and Harry Polihrom, an investigator with the DOBI’s Bureau of Fraud Deterrence, submitted
certifications in support of the motion to quash, plaintiffs should be permitted to compel their testimony at the
time of trial and delve into the factual basis of those statements.
Conclusions of Law
Motion to Quash
Statutes permit the court on motion made promptly to quash or modify the subpoena if compliance would be unreasonable or oppressive.
DOBI argues that our Legislature expressly exempted from subpoena the investigative files of the DOBI. The intent of this exemption,
DOBI maintains, is further reflected in the administrative rules. The grant of this exemption arises from the view that the DOBI
investigative files are law enforcement investigative files and significant public interests are served by
preserving their sanctity. The DOBI maintains that these investigative files must be maintained
confidential otherwise its ability to conduct insurance-fraud investigations would be unnecessarily
hindered, as it would “chill [ ] cooperation with confidential informants or witnesses; ha[ve] a negative
effect on ongoing investigations; and [would] harm[ ] the privacy interests of unindicted persons.”
Moreover, the DOBI asserts that it is within the sound discretion of the DOBI commissioner to “make
relevant papers, documents, reports, or evidence available” and “under such conditions as he deems
appropriate.” Here, the commissioner does not consent to the release of its investigative file to
plaintiffs as DOBI maintains a forced release would “unnecessarily hinder” not only its investigation
into the plaintiffs matter, but the investigations of other similarly situated insurance fraud claims.
New Jersey Insurance Fraud Protection Act
Central to the court’s discussion in this matter is the New Jersey Insurance Fraud Protection Act, N.J.S.A. 17:33A–1 to –30 (the “Act”).
The Act authorizes the DOBI to investigate and pursue civil actions for insurance fraud, and authorizes the OIFP to investigate and
criminally prosecute insurance fraud.
ANALYSIS
Discovery and relevancy
The New Jersey Supreme Court has recognized that the mere assertion of a privilege does not assure confidentiality of the information over
which a privilege has been asserted. A strong presumption of relevancy attaches to discovery material being sought. The person attempting
to overcome the presumption of relevancy the litigant must establish by a preponderance of the evidence that the interest in secrecy
outweighs the presumption. The need for secrecy must be demonstrated with specificity as to each document.
New Jersey courts have recognized that a “government record may be excluded from disclosure by other
statutory provisions or executive orders, or exempt from disclosure due to a recognized privilege or grant
of confidentiality established in or recognized by the State Constitution, statute, court rule, or judicial
decision.” O’Boyle v. Borough of Longport, 218 N.J. 168, 185 (2014) (citations omitted).
Thus, despite public policy interests which favor access to governmental records, both our Legislature
and courts have recognized that certain records may be shielded from production when a recognized
privilege or a risk of danger to public interest has been demonstrated.
Here, plaintiffs’ Subpoena seeks the “entire file or files (including any electronically stored information)
maintained by the DOBI relating to the Gurveys and/or the property” and “any all correspondent, emails,
contracts, photographs, notes, reports, etc., relating to the Property of the Gurveys.” The DOBI’s Bureau of Fraud Deterrence investigative
file was opened for the purpose of conducting “an insurance-fraud investigation.” Plaintiffs have not demonstrated how correspondence,
emails, reports or records related to the DOBFs “insurance-fraud investigation” will have a tendency in reason to prove or disprove the true
market value of the subject property as of October 1, 2010.
As for materials which depict or illustrate the condition of the subject property as of the October 1,
2010 valuation date, they may prove or disprove a fact of consequence with respect to plaintiffs’ cause
of action and therefore, are relevant to the instant matter.
Privilege
However, concluding that all or part of the discovery information sought bears some relevancy and is
thus, probative of a “fact of consequence to the determination of the action” does end the court’s
inquiry. Here, plaintiffs seek access to what is described as the DOBI’s Bureau of Fraud Deterrence
insurance-fraud investigative account involving plaintiffs’ insurer, its agents and representatives. Such
accounts are designed to enable the DOBI’s Bureau of Fraud Deterrence to conduct undisclosed insurance-fraud investigations, solicit
information from witnesses and confidential informants, perform other sensitive law-enforcement functions, and to pursue civil penalties
against those charged with violating the Act. Recognizing this essential government function, our Legislature accorded “[p]apers,
documents, reports, or evidence relative” that are the subject of an insurance-fraud investigation an exemption from public disclosure and
dissemination under the Act.
Waiver of Confidentiality
Plaintiffs argue that any “right to confidentiality” enjoyed by its insurer, their agents and representatives under N.J.S.A. 17:33A–11 was
expressly waived by plaintiffs’ insurer. However, this argument is without merit. Preserving the confidentiality of papers, documents,
reports or evidence in an insurance-fraud investigation under the Act serves substantive public interests, including, preserving the integrity
of the DOBI investigation, the safety and security of witnesses, confidential informants and investigators; enhancing the effectiveness of
investigative techniques; and ensuring the privacy interests of unindicted persons. Thus, while third-parties may share a concomitant
interest in maintaining the confidentiality of the investigative records and documents, the right to confidentiality rests with the DOBI, as
the governmental agency charged with the investigation. The confidentiality afforded by the statute may not be
waived by the subjects of any investigation, any witness, confidential informant, investigator or any other law
enforcement agency, because the right to confidentiality rests with the DOBI commissioner. Accordingly, no
voluntary action by plaintiffs’ insurer, its agents or representatives will serve to waive the statutory right to
confidentiality afforded the DOBI commissioner under N.J.S.A. 17:33A–11.
Unnecessarily hinder investigation
In directing a court of competent jurisdiction to conduct an inquiry into whether the commissioner’s
insurance-fraud investigation would be unnecessarily hindered by the disclosure of information sought under a
subpoena, our Legislature required the court to engage in a balancing process. This analysis requires the court to
engage in a case-by case consideration of whether access would probably so prejudice the possibility of
effective law enforcement that such disclosure would not be in the public interest.
Given the legislative determination that such confidential investigative accounts are subject to disclosure only under the scrutiny of the
DOBI commissioner, a judge must be convinced of a clear showing of advancement of the public interest to warrant disclosure.
Here, the DOBI has demonstrated that important governmental functions and public interests are being served by maintaining the
confidentiality of their investigative accounts, including, but not limited to, the investigation and prevention of insurance-fraud. Moreover,
plaintiffs have made no showing that disclosure of the subpoenaed information would not unnecessarily hinder the DOBI’s insurance-fraud
investigation. Plaintiffs have not demonstrated how issues of fundamental fairness outweigh the DOBI’s strong interests in preserving and
maintaining the confidentiality of its investigative files.
Conclusion
The court concluded, therefore, that the information sought under the Subpoena is specifically exempt
from disclosure under N.J.S.A. 17:33A–11. Moreover, plaintiffs have failed to demonstrate that issues
of fundamental fairness outweigh the DOBI’s competing interest in preserving the confidentiality of
insurance-fraud investigation accounts. Plaintiffs have made no showing that disclosure of the
subpoenaed information would not unnecessarily hinder, obstruct or interfere with the DOBI’s
ongoing insurance-fraud investigation. Consequently, the court granted the DOBI’s motion to quash
the Subpoena.
ZIFL Opinion
A person can obtain official investigative records if charged with a crime. It cannot, however, engage
in a fishing expedition to help the person develop a bad faith case against its insurer. Criminal
investigation records must, as did the New Jersey court, be protected from prying eyes until a criminal charge is brought.
Barry Zalma
Barry Zalma is the principal of Zalma Insurance Consultants. He is available for consultation on any and all insurance issues faced by
you or your clients.
Barry Zalma founded ZIC to help resolve every insurance claim problem faced by you or your clients. His experience and skill as a
consultant and expert witness can make the difference before a jury or other trier of fact. For more than 45 years as a claims person and
insurance coverage attorney, Barry Zalma has represented insurers, advised insurers on claims handling, interpreted coverages and testified
as an insurance coverage, insurance bad faith, insurance claims handling and insurance fraud expert on behalf of
insurers and policy holders’ suing insurers.
Mr. Zalma has been rated “AV Preeminent” for 25 years and is an internationally recognized expert on insurance,
insurance claims handling, insurance coverage, insurance fraud, and insurance bad faith. Barry Zalma will promptly
review your file materials and advise you about the viability of your decision to sue or your defenses. He can help you
narrow the scope of discovery.
Consultation with Mr. Zalma and ZIC can save you or your client thousands of dollars in the defense or prosecution of
an insurance dispute. ZIC will assist you in the effort to find a solution to an insurance claims dispute that is fair,
intelligent, beneficial and economical.
ZIC is available to provide expert advice and, if needed, expert testimony to individuals and their counsel. Advice from
ZIC is indispensable to the resolution of insurance disputes. Consultation from ZIC can save you, your counsel or client hundreds of hours
of investigative and legal work.
With comprehensive knowledge of insurance and insurance claims handling Mr. Zalma understands, and can explain in language a lay jury
understands, how and why insurance claims should be resolved.
ZIC rates are all inclusive. Mr. Zalma’s hourly fee takes account of all incidentals from telephone calls and postage.
Insurance Fraud Investigation
The purpose of an insurance fraud investigation is to gather evidence to establish whether a suspected fraudulent
claim is legitimate or is, in fact, an attempt to defraud the insurer.
If the facts reveal the claim is legitimate, the fraud investigation stops and the claim is paid. If the facts support
the suspicion, then further evidence must be gathered to allow the insurer to successfully deny the claim and
refuse to pay.
Training the Investigators
The introduction of the tort of bad faith resulted in the insurance industry running scared for many years from
investigating fraud. Insurers avoided denying claims fearful that they would subsequently be sued for bad faith.
Insurers discouraged their adjusters from looking too closely at claims. As a result, knowledgeable personnel
either looked for another career or were laid off by companies interested in improving their bottom line by hiring
the less experienced personnel.
Insurance fraud investigations are often expensive. The extent of insurance fraud, depending on which of the
various estimates are believed vary from $80 billion to $300 billion dollars every year. The sum is so enormous
as to defy understanding. Insurers are finding that they cannot increase premiums to honest insureds fast
enough to cover the amounts lost to fraud. They cannot afford to let such an enormous amount of money
deplete their assets and destroy their profits without a fight.
The first line of defense to stop the hemorrhage of billions of dollars to fraud perpetrators is a staff of
well-trained experienced and professional adjusters and investigators.
Although many adjusters will never witness the sorts of frauds described in this book they must be trained to recognize fraud, and thus be
equipped with enough knowledge to separate the suspicious from the honest claim. States are, like California, requiring that insurers train
all of their claims personnel to recognize insurance fraud, attempted insurance fraud and the indicators or red flags of insurance fraud. The
laws and regulations attempting to force the victim of the crime, insurers, to investigate and prepare prosecutions for the state, are
unfortunately honored more in the breach than in the following.
What A Fraud Trained Adjuster Must Understand
To turn a claims person into a fraud trained adjuster, the adjuster must become familiar with all of the
following:
1.
all insurance policy contracts used by the insurer;
2.
the rules applied by the courts for the interpretation of insurance contracts;
3.
the Fair Claims Practices Act of the jurisdiction in which they work;
4.
the regulations promulgated by the Department of Insurance in their state to enforce the Fair
Claims Practices Act;
5.
The statutes in their state compelling the existence of a Special Investigation Unit (SIU);
6.
The regulations established by their state concerning the training and operation of the SIU and claims personnel;
7.
The law of contracts;
8.
The law of torts;
9.
The law of fraud;
e.
10.
The obligations of an insurer to pursue anti-fraud activities;
11.
Specialized knowledge for different types of claims, such as:
a.
sufficient medical terminology to understand the diagnoses of physicians;
b.
treatment of traumatic injuries;
c.
cost of reasonable medical treatment for traumatic injuries;
d.
methods for determining the extent of damage to structures or vehicles and the cost of repair or
replacement;
methods for establishing the fair market value of items of personal property, including vehicles;
12.
Interview techniques that facilitate the obtaining of detailed information;
13.
Negotiation skills required for obtaining fair, reasonable, and acceptable settlements; and
14.
The red flags of fraudulent claims.
This training does not occur overnight. It is a tall order that requires commitment by each insurer to thoroughly train
their adjusters and other claims personnel concerning the indicators of fraud. Fraud training, by computer assisted
training programs, is available for minimal costs from private vendors like National Underwriter Company, IRMI, A.D.
Banker, IRMI’s WebCE, this book, and other materials published by the author. In addition various insurer produced
programs exist as well as programs by independent adjusting firms.[1]
Basic classroom type training for insurance personnel is available across the country in local colleges and universities.
Local colleges, community colleges, universities and law firms will provide training at little or no cost. The training
programs should be supplemented by meetings between supervisors and claims staff on a regular basis to reinforce and
supplement the information learned.
The insurer should also institute a regular program of auditing claims files to establish compliance with the subjects studied to see how
effective the training was to discover and defeat fraudulent claims. Monthly meetings should be held with claims staff to reinforce what
was learned in the training sessions and to discuss current investigations where fraud is suspected.
There is no quick and easy way to create insurance claims professionals who are knowledgeable about insurance fraud. The training takes
time. The learning takes longer. Those adjusters and other personnel who take the fraud training seriously and apply it to existing claims
should be rewarded and honored for their skill. Without applying the training to actual claims the training is wasted.
Red Flags of Fraud
Suspicious claims have common attributes. Insurers and their anti-fraud organizations have collated the common attributes into lists of
indicators or red flags of fraud. The lists were created as training aids and to be used to determine whether
further investigation is required to determine if a claim is legitimate or false and fraudulent. Continually
growing, these lists are known as the “red flags” or “indicators” of fraud lists. There are many different
categories, ranging from those associated with the claim itself or with insureds to indicators of specific types of
fraud, such as bodily injury fraud or arson for profit.
If, when assessing a claim, three or more red flags are found the need for further investigation should be
considered and evaluated by the claims person, a supervisor and the insurer’s special investigative unit. The
existence of red flags does not mean a fraud has occurred. Red flags are only a signal to the adjuster to investigate further so that the
suspicion may be either removed or confirmed. It is not any single indicator that alerts the adjuster to the possibility of a fraudulent claim
but a combination of the red flag or red flags discovered coupled with the results of the thorough claims investigation.
Although the existence of multiple red flags should trigger an investigation, failure to investigate has been held to be reasonable as long as
there are no patent inaccuracies or actual knowledge of false representations. In a Missouri case, the following “red flags” were found to be
a reason for an insurer to suspect arson for profit:
•
more than one mortgage,
•
late payments,
•
divorce,
•
prior claims,
•
multiple claims,
•
problems affecting title to the property,
•
over-insurance,
•
an increase in insurance coverage right before the claim,
•
recent cancellations of insurance held with prior insurers,
•
liens,
•
threats of foreclosure on the property,
•
lawsuits, and
•
recent job transfers.
As the Nebraska Department of Insurance states in its booklet, Fraud Detection Hints, it is “important to remember that the … possible ‘red
flags’ [indicate] that there may be some evidence consistent with an insurance fraud scheme. Any one or two of these by themselves may
not raise your suspicions; however, when you have several of these hints (red flags) present or a pattern begins to emerge, you should
investigate further or forward your suspicion to the Insurance Fraud Prevention Division.”
Specific to the training requirements of the state of California is Barry Zalma’s e-Book, Zalma On California SIU Regulations, available at
http://www.zalma.com/zalmabooks.htm.
This article was adapted from Barry Zalma’s new e-book, “Insurance Fraud and Weapons to Defeat Fraud, only available from Zalma
Books at http://www.zalma.com/zalmabooks.htm.
Proformative Academy
I have prepared webinars for Proformative Academy on various subject that might be of interest to you. You can get a
discount for the programs I have prepared by using the coupon code. Your coupon code is: Zalma10. Go to
http://bit.ly/1kFabsE?ccode=Zalma10 to try Proformative. directly (no spaces in between, and include the question mark “?”)
to the URL you send them, and, just as before, your coupon code will be automatically entered even if they look at your
course first, tool around the site a bit, and then finally go to buy a subscription. Simple! They include:
Insurance Fraud - An Overview
I have created for Proformative Academy two webinars called “Insurance Fraud - An Overview” that is available at
http://www.proformative.com/courses/insurance-fraud-prevention and “How to Read and Understand Business Insurance
policies. Both come with a 10% Discount for my friends and clients who sign up and enter the discount code: Zalma10.
Insurance Fraud is estimated to take between $80 and $300 billion a year from the property and casualty insurance industry, raising the
prices each person pays for insurance by more than $300 a year. It explains to those attending what insurance fraud is, various methods by
which insurance fraud is perpetrated, and the various weapons provided by statutory law, legal precedent and
professional claims handling to work to reduce the amount stolen by fraud perpetrators. It explains the use of
red flags or indicators of insurance fraud and the use of an insurance company Special Investigation Unit
(SIU) to gather the evidence necessary to assist in the defeat of insurance fraud.
How To Successfully Present a Commercial Property Insurance Claim
No business can operate profitably without insurance to protect it against contingent or unknown catastrophic
losses. By spreading the risk among many businesses, insurers can charge reasonable sums to protect against
losses to the business or its real and personal property. As you listen to an internationally recognized insurance coverage lawyer, author,
consultant and expert witness explain how to gather the information necessary to present a claim to your insurance company and collect the
information required to effectively present a claim to gain full indemnity, you will be convinced you can do so with minimal or no
assistance.
http://www.proformative.com/courses/how-successfully-present-commercial-property-insurance-claim
How to Read & Understand Business Insurance Policies
No business can operate profitably without insurance to protect it against contingent or unknown catastrophic
losses. By spreading the risk among many businesses, insurers can charge reasonable sums to protect against
losses to the business or its real and personal property. In this course you will listen to an internationally
recognized insurance coverage lawyer, author, consultant and expert witness explain why and how an insurance
policy provides protection for the business. A business person with the ability to read and understand the
insurance policies they acquire has an advantage over every other business person who cannot read and
understand a such policies.
Continuing Education Credit available for many, including Certified Fraud Examiners with 1.5 CPE Credits, in Fraud Prevention and
Deterrence. I hope you find it interesting and informative.
http://www.proformative.com/courses/how-to-read-understand-business-insurance-policies
Some Red Flags or Indicators of Fraud
Suspicious claims have common attributes. Insurers and their anti-fraud organizations have collated the
common attributes into lists of indicators or red flags of fraud. The lists were created as training aids and
to be used to determine whether further investigation is required to determine if a claim is legitimate or
false and fraudulent. Continually growing, these lists are known as the “red flags” or “indicators” of
fraud lists. There are many different categories, ranging from those associated with the claim itself or with insureds
to indicators of specific types of fraud, such as bodily injury fraud or arson for profit.
If, when assessing a claim, three or more red flags are found the need for further investigation should be considered
and evaluated by the claims person, a supervisor and the insurer’s special investigative unit. The existence of red
flags does not mean a fraud has occurred. Red flags are only a signal to the adjuster to investigate further so that the
suspicion may be either removed or confirmed. It is not any single indicator that alerts the adjuster to the possibility of a fraudulent claim
but a combination of the red flag or red flags discovered coupled with the results of the thorough claims investigation.
Although the existence of multiple red flags should trigger an investigation, failure to investigate has been held to be reasonable as long as
there are no patent inaccuracies or actual knowledge of false representations. Red flags are indicators that require an insurer to thoroughly
investigate a claim to determine if there is any evidence that would allow an insurer to determine that evidence exists that would be
admissible to establish, by a preponderance that fraud had been attempted. If the evidence is not found the claim must be paid. Some of the
indicators follow:
1.
The insured has lived at his current address less than six months.
2.
The insured has been with current employer less than six months.
3. The insured has a previous history of losses.
4. The insured cancels scheduled appointments with the adjuster for statements and/or Examination Under
Oath.
5. The insured is employed with an insurer.
6. The insured is unusually aggressive and pressures for a quick settlement.
7. The insured does not have a telephone.
8. The insured’s telephone number is only a mobile cellular phone.
9. The insured is difficult to contract.
10. The insured claims to be self-employed but is vague about the business and his responsibilities.
11. The insured is very knowledgeable about claims process and Insurance terminology.
12. The insured offers inducement for a quick settlement.
13. The insured is unsolicited new, walk-in business, not referred by an existing policyholder.
14. The insured’s address is not consistent with his employment or income.
15. The insured only gives a post office box as his address. The insured is unemployed or in a transient occupation.
16. The insured seeks a copy of the policy before agreeing to insure.
17. The insured is vague about loss.
18. The insured’s report of loss is inconsistent.
19. The insured has a selective memory.
20. The insured has financial difficulties.
This article was adapted from Barry Zalma’s new e-book, “Insurance Fraud and Weapons to Defeat
Fraud, only available from Zalma Books at http://www.zalma.com/zalmabooks.htm.
Good News From the
Convictions
* A kingpin of America’s largest no-fault crash ring ever has 25 years in a federal prison to rethink how fraud fighters pried apart his
crime ring. Michael Danilovich’s 5-year crime spree lifted at least $100 million in faulty no-fault injury
claims from setup wrecks. A network of crooked clinics delivered phantom, worthless and inflated
injury treatment for bogus car passengers. MRI, acupuncture and chiro clinics feasted on insurers. Docs
were on the take, illegally installed as stooge clinic owners. Lay ring members illegally ran the
operations behind the scenes. Recruiters received kickbacks to deliver patients for batteries of unneeded
tests and treatments. Danilovich laundered the money via check-cashing services and shell companies.
The loot bought Danilovich luxury vacations, cars and watches. He was taken down by RICO charges.
His co-kingpin Mikhail Zemlyansky received 15 years and the most-feared fate of all: induction into the
notorious Insurance Fraud Hall of Shame.
* Getting a first whiff of staged-crash profiteering as a fake passenger impelled Gustav Romiro Acuna-Rosa to open his own
physical-therapy clinic to con auto insurers. Cohorts in a complex crash ring bribed the Lansing, Mich. man $1,000 to take part as a fake
passenger. He got useless treatment at Revive Therapy Center, billed to auto insurers. Acuna-Rosa then opened up his own
physical-therapy clinic, Renue Therapy Center. He paid other ring members to take part in setup crashes and get treatment at his clinic.
Acuna-Rosa billed auto insurers as much as $550,000 for false injury treatment. He could spend up to 10 years in federal prison when
sentenced Nov. 28.
* The general manager of a car dealership helped husband-wife plotters falsify a car loan application to buy a $139,000 Bentley they
later torched after reporting it stolen to their insurer. Hector Marquez pleaded guilty to helping facilitate the plan at the Teterboro, N.J.
dealership. As for the Bentley, Chester and Anna Jarzabek allegedly bought the car from their son John, who worked at a now-defunct
dealership. The husband-wife duo submitted falsified documents to inflate their income and get financing, prosecutors say. The Jarzabeks
still face charges. Marquez, meanwhile, could spend up to 7 years in state prison for his insurance crime and 16 years when sentenced for
false finance loans involving luxury cars.
* The baker’s half-baked comp con fell flat. Yurizan Cuevas tried to stop a robber from stealing from the Seattle café where she was a
baker and cashier. Cuevas hit a wall and injured her back trying to stop a crook from robbing the café, she claimed. Medical
providers verified Cuevas was too injured to work, so she started collecting workers-comp from the state Department of
Labor & Industries. But investigators caught Cuevas working as a full-time nanny for almost 2 years while collecting comp
money. Yet Cuevas stated on comp forms that she couldn’t work at all. Cuevas received 20 days in jail, converted to 160
hours of community service. She also must repay L&I $24,847.
* A semipro football player’s comp scam was sacked. Jason Fitch claimed he hurt his knee while kicking a bag during training while
working for the Oklahoma County Sheriff’s Office. He started collecting workers-comp money. Yet no witnesses recalled Fitch being hurt
during the incident. Nor did his stories add up. His first doc released him for regular duty. Then he showed up 3 months later, claiming a
worsening knee injury after duping another doc. Turns out Fitch hurt his knee while playing for the Oklahoma City Bounty Hunters
semipro gridiron team. He received 2 years of probation. No word on job status.
* A betrayed client exposed agent Cristian Raul Videla’s premium thefts. The Van Nuys, Calif. agent sold cargo coverage to truckers.
He bought the truckers less protection than they paid for, and pocketed the difference in premiums. Videla also issued bogus insurance
certificates showing full coverage. The scheme rolled along until a trucker had a $100,000 loss. He didn’t have enough coverage and had to
pay $50,000 of the total, the insurer said. Videla pleaded no contest after an investigation by the state insurance department. He received 5
years of probation and must repay his 5 victims.
* A Miami psychiatrist who became a national symbol of fraudulently over prescribing addictive
painkillers billed to insurers said his 97,000 scripts were “completely outside of my character.” Dr. Fernando
Mendez-Villamil ran one of the largest fake-prescription scams in history. He and 3 employees launched an
elaborate scheme to provide bogus diagnoses of debilitating psychiatric conditions so numerous people could
falsely qualify for Social Security disability benefits, Medicare and Medicaid. They also were exempt from testing to become U.S. citizens.
Mendez-Villamil then filed false claims with Medicaid and Medicare for unneeded prescriptions and medical services to create bogus
medical records. Mendez-Villamil offered to help a cohort falsely obtain disability benefits in exchange for that individual entering into a
bogus marriage for immigration purposes. The feds raided Mendez-Villamil’s home and impounded 221 paintings, prints
and sculptures. He filed an “acceptance of responsibility” statement to try and reduce his federal sentence.
* Alana Wells worked at a medical provider, where she had access to patient info that HIPAA protected from
disclosure. Wells stole the names, dates of birth and SSNs of patients from the database and provided the identities to
co-conspirator Fredrick Hill. He handed the info to the ringleader Christopher Davis who, along with others, used it to
file bogus federal tax refunds. Hill is serving 74 months in federal prison and Davis 60 months. Wells could spend up to
7 years when sentenced. A sentencing date is being set.
* A driver collided with Jamilla Caston’s vehicle in a parking lot. The driver’s insurer State Farm paid Caston $5,600 for injuries, pain
and suffering. The Olympia, Wash. woman kept some of the money because her health insurer paid the bills, the state insurance department
says. Caston was involved in another crash several months later and submitted medical bills from the first collision to the at-fault driver’s
insurer Nationwide. The insurer caught the scam and the insurance department investigated. Caston bolted after failing to appear in court.
She was picked up in the Las Vegas area. Caston received 80 hours of community service, and must repay the $5,600 plus court costs.
* Business partners Jason Kwon and David Chang swiped unsuspecting customer cellphone account info and driver licenses to scam
insurers. The Los Angeles pair owned separate cellphone stores. They forged claim forms to file for purportedly lost, damaged or stolen
phones using the customer info. They told their insurer to ship replacement phones to a given address. The dialing duo then sold the phones
for profit. Kwon and Chang made more than 1,000 false claims and billed their insurer at least $1.3 million. Kwon received a year in jail
and 5 years probation. Chang also received 5 years probation, but only 3 months in jail. Both repaid $517,502, with $360,000 going to the
victim insurer.
* Keith Capodicasa crashed into another car on June 9, 2015, then told Progressive Insurance someone
stole it. The Erie County, N.Y. sheriff’s deputy received $21,608. His car turned up in a Buffalo parking ramp
with a ticket stamped June 9. Capodicasa pleaded to a light insurance-fraud misdemeanor. He’s repaid the
money. A felony would’ve ended his career, and the misdemeanor gives the department discretion to
determine Capodicasa’s career prospects.
* A routine traffic stop discovered an insurer employee’s theft of more than 50 medical identities of patients. Quinzella Romer had
an outstanding warrant, officers found. So they did a routine pat-down. The South Florida woman had someone else’s driver license and
name. A search of her cellphone revealed more than 20 screenshots of at least 50 names, SSNs and DOBs of health-insurer customers.
Romer was the disability-benefit manager at an insurer, and the names came from her workstation. Romer received 32 months in federal
prison.
* In Brief … Several Louis Vuitton items were stolen from Rebekha Ruth Eisner’s home, the Las Vegas-area woman claimed. She
actually returned the goods to the Louis Vuitton store in Newport Beach, Calif. several years earlier. Eisner pleaded guilty and will be
sentenced Oct. 31. … Agent Sanny Cazares sold a business owner a general liability policy for $1,960. The Pomona, Calif.-area agent
never sent the premium to the insurer. The victim business was exposed for 3 months. Cazares received 3 years of probation, must repay
the premium and lost her license. … A mere clerical error, dentist John Moon said in explaining his billing Delta Dental $328,000 for
phantom services. The court didn’t buy the Half Moon Bay, Calif. doc’s line. He received 3 years of supervised probation and has repaid
about $200,000.
It’s Not Nice To Lie to Get Life Agency Appointment
Obtaining Life Insurance Agency Agreement by Misrepresentation is Criminal & Collection of Commission
is Theft
Insurance companies involved in a business of utmost good faith believe applications presented to them by
licensed insurance agents and brokers who wish to represent them in the sale of life insurance. They do not
conduct an investigation of the applicant but, rather, rely on the applicants good faith in seeking the agency
appointment.
In Young v. State, Court of Appeals of Indiana, No. 29A02–1508–CR–1240, 2016 WL 3763452 (July 14,
2016) Edward A. Young obtained an agency appointment with a life insurance company although he had
no license by using the name and license number of a licensed agent who was an acquaintance.
FACTS
Irene Gentry is an independent insurance agent and, during the period of time relevant to this case, was
licensed to sell life, accident, and health insurance. Edward A. Young and Gentry became friends and
attended prayer meetings together. She was aware that he was also an independent insurance agent and
occasionally referred customers to him.
Young’s family owned Liberty Insurance Agency, LLC. His wife and son were listed as Liberty
Insurance’s officers on documents filed with the Indiana Secretary of State. In 2010, an employee of
Liberty Insurance helped Gentry apply for life insurance for herself. She filled out an application
containing information including her address, social security number, and date of birth. By 2012, Young
and his wife had surrendered their licenses to sell insurance in Indiana, but Liberty Insurance continued to operate.
In early 2012, Fidelity Life Association, a life insurance company, received a “General Agent Application” that purported to have been
signed by Irene Gentry on February 29, 2012. Gentry neither prepared nor signed the application and did not authorize anyone to prepare it
or sign it on her behalf.
The applicant asked Fidelity Life to appoint Gentry to sell Fidelity Life’s policies. The applicant further asked Fidelity Life to pay Gentry’s
commissions to Liberty Insurance. The application had several attachments, including an authorization for electronic fund transfers of
commissions to Liberty Insurance’s bank account. In another attachment, Gentry was incorrectly identified as the Vice–President of
Liberty Insurance. The application also included a federal W–9 form, entitled “Request for Taxpayer Identification Number and
Certification.” The W–9 form was purportedly signed by Gentry on behalf of Liberty Insurance. On the W–9 form, an address was listed
for Liberty Insurance that was, in reality, Young’s home address.
Fidelity Life accepted the application and authorized Gentry to sell its insurance policies as an independent
agent. Fidelity Life paid commissions to Liberty Insurance’s employees, including Young, his son, and his
daughter-in-law. The commissions were advance payments, based on a projection of the premiums the
policyholders are expected to pay. In this case, policyholders failed to pay the premiums for several Fidelity
Life policies sold by Liberty Insurance’s employees. Fidelity Life deemed Gentry, the person who allegedly
signed the application, to be ultimately responsible for the debts.
Meanwhile, in December 2012, Gentry applied to Oxford Life to sell their insurance policies. She had not previously been an agent of that
company. Oxford Life informed her she was already their appointed agent through Liberty Insurance and owed them money for advance
commissions on premiums that were not paid. The company further informed Gentry that, due to her unpaid debt, it had listed her on
Vector. Vector is a list of insurance agents who owe debts to insurance companies. After obtaining additional information from Oxford
Life, Gentry contacted Young. When Gentry told Young that Oxford Life had placed her on Vector due to Liberty Insurance’s actions, he
promised to resolve the situation “today.” He acknowledged writing policies in her name without her consent or permission.
An investigator employed by Oxford Life contacted Young, who acknowledged in a recorded phone conversation that he entered into an
agreement with Oxford Life using Gentry’s name “without her consent or even her knowledge.”
The State charged Young with forgery (in relation to the false application submitted to Fidelity Life), insurance fraud (in relation to the
false commission reports submitted to Fidelity Life), and theft (taking unearned funds from Fidelity Life). A jury determined Young was
guilty as charged.
DISCUSSION AND DECISION
The purpose of voir dire is to determine whether potential jurors can render a fair and impartial
verdict in accordance with the law and the evidence. Voir dire panelists may be asked questions to
identify bias but not to condition them to be responsive to the questioner’s position. Proper
examination may include questions designed to disclose the panelists’ attitudes about the type of
offense charged.
The hypothetical used by the prosecutor in voir dire focused on core jury functions such as
assigning responsibility for offenses and weighing witness credibility. As a result, the hypothetical
did not amount to prosecutorial misconduct as Young contends, much less fundamental error.
ADMISSION OF EVIDENCE
Young claims the trial court should not have admitted a recording of a phone conversation between Young and an investigator for Oxford
Life. The admission and exclusion of evidence falls within the sound discretion of the trial court and is reviewed only for an abuse of
discretion. In this case, the jury heard Exhibit 9, a recording of a telephone conversation between Young and an investigator for Oxford
Life. During the recording, Young admitted to the investigator that he entered into an agreement with Oxford Life
using Gentry’s name “without her consent or even her knowledge.” He further stated, “I got her into this bit with
your company, and it’s wrong.”
Finally, the trial court read a limiting instruction to the jury. On appeal the appellate court presumed the jury
obeyed the court’s instructions. As a result, any prejudice from the admission of Exhibit 9 did not substantially
outweigh its probative value, and the trial court did not abuse its discretion.
SUFFICIENCY OF THE EVIDENCE
On a challenge to the sufficiency of the evidence, the court does not reweigh the evidence or judge the credibility of the witnesses. Instead,
the court respects the jury’s exclusive province to weigh conflicting evidence.
In order to convict Young of forgery as a Class C felony, the State was required to prove beyond a reasonable doubt that: (1) Young (2)
with the intent to defraud (3) made or uttered (4) a written instrument (5) in such a manner that it purported to have been made (6) by
another person. Young claims he did not make or utter the false application that was submitted to Fidelity Life in Gentry’s name requesting
her appointment as an independent agent.
The evidence most favorable to the judgment reveals Young had access to Gentry’s personal information because she had applied for life
insurance through Liberty Insurance. Young admitted to a Fidelity Life investigator that he had “created a debt” for Gentry “without her
approval or consent.” This is sufficient evidence from which the jury could have reasonably determined
Young forged the application.
The record establishes that Young, who had surrendered his insurance agent license to the Indiana Department
of Insurance, began an agency relationship with Fidelity Life in Gentry’s name, and he knew he did not have
her “approval or consent.” Gentry had a valid insurance agent license. The jury could reasonably extrapolate
from this evidence that Young intended to fool Fidelity Life into believing it had established a relationship
with Gentry, with the plan of receiving commissions from Fidelity Life for selling its policies. This is ample
evidence of intent to defraud.
INSURANCE FRAUD
In order to convict Young of insurance fraud as a Class C felony, the State was required to prove beyond a reasonable doubt that: (1)
Young (2) knowingly and with intent to defraud (3) caused a statement containing false, incomplete or misleading information (4) to be
presented to an insurer (5) and caused economic loss in an amount exceeding $2,500. Young claims the State failed to prove he caused any
economic loss. As a result, Fidelity Life placed Gentry on Vector, an insurance industry blacklist “that pretty much paralyzes you.” If you
are put on the list, “you can’t do business.” A jury could reasonably infer from this evidence that Gentry had experienced lost income and
other costs greater than $2,500 as a result of Young filing false claims with Fidelity Life.
Young argued the State failed to present sufficient evidence of any intent to defraud. He admitted to Fidelity Life’s investigator that he
wrote policies submitted to Fidelity Life in Gentry’s name, and advance commissions were “effectively, paid to [him].” Further, Young
admitted that what he did was “wrong doing” for which he needed to make restitution.
ZIFL OPINION
The appeal was spurious. Young knew what he did to get an appointment with Fidelity Life was based upon false and fraudulent conduct
and, that in so doing, he caused damage to his friend Gentry who was effectively put out of business by making her appear to be a scofflaw
who did not repay debts owed to insurers she represented.
New E-Books from Barry Zalma
Random Thoughts on Insurance – Vol. IV
Since 2010 I have been writing a blog post at least five days a week. This e-book is a collection of those posts that reveal
my interest in insurance case law from 2014 to 2016. Some of the cases reviewed were important. Some were of first
impression. Others will be totally unimportant. All were interesting to me and I hope are interesting to the reader. This
e-book is more than 700 pages of my review of interesting cases from 2013 through January 2014.
After you purchase please wait for the e-book to upload from PayPal. If it does not upload please e-mail [email protected] and I will
personally send you a copy of the e-mail in pdf format.
Fraud and Weapons to Defeat Fraud”
Insurance fraud continually takes more money each year than it did the last from the insurance buying public. There is no certain number
because most attempts at insurance fraud succeed. Estimates of the extent of insurance fraud in the United
States range from $87 billion to more than $300 billion every year.
Insurers and government backed pseudo-insurers can only estimate the extent they lose to fraudulent claims.
Lack of sufficient investigation and prosecution of insurance criminals is endemic. Most insurance fraud
criminals are not detected. Those that are detected do so because they became greedy, sloppy and
unprofessional so that the attempted fraud becomes so obvious it cannot be ignored.
No one will ever be able to place an exact number on the amount lost to insurance fraud. Everyone who has looked at the issue knows –
whether based on their heart, their gut or empirical fact determined from convictions for the crime of insurance fraud – that the number is
enormous.
When insurers and governments put on a serious effort to reduce the amount of insurance fraud the number of claims presented to insurers
and the pseudo-government-based or funded insurers drops logarithmically.
The e-book contains the full text of the most important insurance fraud cases in over 2000 pages of material essential to every insurance
fraud professional.
Available at http://www.zalma.com/zalmabooks.htm
“Getting the Whole Truth”
The interview is an essential form of fact gathering for every type of human interaction. Interviews happen everywhere; they are performed
by almost everyone. Interviewing is also an art, and the most effective interviews are conducted by those who are knowledgeable and
skilled in this art.
The purpose of an interview is to uncover the truth; the method of uncovering the truth is the art of the interview. The standard interview
does not have, nor should it be given, the pejorative sense conveyed by the expression “giving someone the third degree.” Interview
professionals do not use rubber hoses or hot lights, or subject the interviewee to torture. In their limited arsenal,
professionals do not have the power of the state, the reputation of the FBI, the majesty of a court trial, nor the
intimidation of a search warrant.
Civil interviewing professionals are, therefore, compelled to get the information they need by intelligence, wit, skill,
and experience. They must be masters of the social graces; they must know how to put people at ease. The skill of the
professional causes the person being interviewed to actually want to give information to the interviewer. When the
interview is successful, the subject becomes a virtual partner with the professional in the effort to uncover the truth,
the whole truth, and nothing but the truth.
This ebook will help anyone who needs to obtain information from anyone else gain the information needed whether a business person,
reporter, interviewer, investigator or lawyer.
The book will be delivered to you by e-mail shortly after purchase.
Wisdom
“When you get into a tight place, and everything goes against you till it seems as if you couldn’t hold on a minute longer, never give up
then, for that’s just the place and time that the tide’ll turn.” - Harriet Beecher Stowe
“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take
the lead in the introduction of a new order of things.” – Niccolo Machiavelli
“Let us recollect that peace or war will not always be left to our option; that however moderate or unambitious we may
be, we cannot count upon the moderation, or hope to extinguish the ambition of others.” — Alexander Hamilton
“If you are not fired with enthusiasm, you will be fired with enthusiasm.” - Vince Lombard
“Don’t worry about avoiding temptation. As you grow older, it will avoid you.” - Winston Churchill
“History teaches us that men and nations behave wisely once they have exhausted all other alternatives.” – Abba Eban
“Far and away the best prize that life offers is the chance to work hard at work worth doing.” - Theodore Roosevelt
“By all means, marry. If you get a good wife, you’ll become happy; if you get a bad one, you’ll become a
philosopher.” - Socrates
“Sometimes, when I look at my children, I say to myself, ‘Lillian, you should have remained a virgin.’” - Lillian
Carter (mother of Jimmy Carter)
“I suppose, indeed, that in public life, a man whose political principles have any decided character and who has energy
enough to give them effect must always expect to encounter political hostility from those of adverse principles.” —
Thomas Jefferson
“Leadership consists of nothing but taking responsibility for everything that goes wrong and giving your subordinates
credit for everything that goes well.” - Dwight D. Eisenhower
The Zalma Insurance Claims Library
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Citations to model statutes, state statutes, administrative regulations, and requirements of insurance departments
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» Duties of insured and insurer
» Processing a claim
» Evaluation and settlement
» Responses to fraud
» Identifying insurance fraud
» Subrogation and salvage
» Investigation
» Underwriting
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Health Insurance Fraud Convictions
Arkansas Doctor Gets 2-Year Sentence in Insurance Fraud Case
Robert Barrow, a Little Rock, Ark., doctor whose clinic improperly billed massage therapy services as physical therapy has received two
years in prison and has been ordered to pay insurers and patients more than $700,000 in restitution.
Barrow pleaded guilty to healthcare fraud conspiracy. He said he had been deliberately ignorant to the fact that
his office used a billing code for physical therapy services to seek get more than $2.2 million over a
seven-year period for services which are not usually covered by insurance companies.
Federal prosecutors say Barrow contracted two massage therapists to use space at the Your Doctor’s Office
clinic and that in exchange for low rent and overhead expenses, the therapists agreed to give Barrow a
percentage of the profits from services they performed on patients Barrow referred for physical therapy.
Authorities say an investigation showed that patients believed they’d been receiving and paying for physical therapy.
Barrow maintained that billing errors were his staff’s fault, but told a judge that he did not regularly review the therapists’ records to make
sure patients were being properly treated and progressing.
The investigation was started after an insurance employee was surprised that the small clinic was the second-highest biller of physical
therapy services in the state, even surpassing clinics that specialize in rehabilitative and physical therapy services.
Barrow’s medical license was suspended after he pleaded guilty.
Immigrant Guilty of Staged Accident Scheme
Carlins Calixte, 32, of Norwich, Connecticut pleaded guilty July 7, 2016 before U.S. District Judge
Jeffrey A. Meyer in New Haven to one count of conspiracy to commit mail and wire fraud stemming
from his involvement in an insurance fraud scheme.
According to court documents and statements made in court, between April 2011 and February 2014,
Calixte and others conspired to stage approximately 50 car crashes in southeastern Connecticut for
the purpose of defrauding automobile insurance companies and enriching themselves. A high percentage of these planned crashes were
single-vehicle accidents on remote roads where there were no witnesses other than the occupants of the crashed vehicle. After each staged
accident, the defendants filed fraudulent property damage and bodily injury claims with various automobile insurance companies. They
then collected payouts on the fraudulent claims from the victim insurance companies. These payouts typically ranged from about $10,000
to about $30,000 per accident.
In pleading Guilty, Calixte admitted his personal involvement in at least seven staged crashes. After each crash, Calixte either filed a
fraudulent property damage or bodily injury claim with his or another participant’s automobile insurance provider, or he aided and abetted
other participants in their submission of fraudulent claims.
Calixte was arrested on May 23 and is released on bond. He is a citizen of Haiti and a lawful permanent resident of the U.S.
Judge Meyer scheduled sentencing for September 30, 2016, at which time CALIXTE faces a maximum term of imprisonment of 20 years.
Guilty of $1.6 Million Health Care Fraud
Patricia Lafayette, 61, of Torrington, Connecticut waived her right to indictment and pleaded guilty before U.S. District Judge Victor A.
Bolden in Bridgeport to one count of health care fraud.
The investigation by U.S. agencies identified fraudulent activity in the area of behavioral health services.
Through the Medicaid program, the State of Connecticut provides coverage for mental health and
counseling services to citizens who cannot otherwise afford health insurance. “Behavioral health” includes
a wide variety of health care providers who provide care on an outpatient basis, including psychiatrists,
psychologists, licensed clinical social workers, licensed marriage and family therapists, licensed
professional counselors, and licensed alcohol and drug counselors.
According to court documents and statements made in court, in March 2011, Lafayette and another
individual approached Anne Charlotte Silver, a licensed clinical social worker who owned and operated Silver Counseling Services, LLC,
in Canton and Bantam. Lafayette knew that the other individual proposed a scheme to Silver to defraud Medicaid by permitting Lafayette
and the other individual to bill Medicaid for psychotherapy services using Silver’s Medicaid provider number. The services were either
performed by unlicensed individuals or not performed at all. Under the scheme, Silver kept 25 percent of the proceeds, and paid the
remaining 75 percent to Lafayette and the other individual. As part of her plea, Lafayette admitted to defrauding Medicaid of
approximately $1.6 million through the scheme.
The charge of health care fraud carries a maximum term of imprisonment of 10 years. A sentencing date has not been scheduled.
Jury Convicts Houston Registered Nurse in $8 Million Medicare Fraud Scheme
Ann Anyanwu, 53, of Harris County, Texas, a registered nurse was convicted July 19, 2016 by a federal jury in the
Southern District of Texas for participating in an $8 million Medicare fraud scheme involving fraudulent claims for
home-health services.
Anyanwu was convicted of three counts of a scheme to defraud Medicare following a jury trial before U.S. District
Judge Alfred H. Bennett of the Southern District of Texas. Anyanwu is scheduled to be sentenced on Sept. 8, 2016.
From January 2012 through June 2015, Anyanwu and others executed a scheme to submit through Medpsych Home Health Care
(Medpsych) approximately $8 million in false and fraudulent claims for home-health services to Medicare. The evidence showed that
beneficiaries for whom Medpsych billed Medicare did not receive home-health services, and many did not qualify for home-health
services.
In addition, the evidence showed that Anyanwu created false medical records for nursing services – treatment
that she never provided – and falsified other records of Medpsych to make it appear as if she provided nursing
services when, in fact, she did not.
To date, two others have been charged for their roles in the scheme. Precious Deshield, the former owner,
director of nursing and administrator of Medpsych, pleaded guilty to conspiracy to commit healthcare fraud
for her role in the scheme. Roland Johnson, the owner and operator of Medpsych, also pleaded guilty to
conspiracy to commit healthcare fraud. Deshield and Johnson currently await sentencing before Judge
Bennett.
Doctor Heads to Prison for 63 Months for Home Health Care Fraud
Dr. Warren Dailey, 68, a Houston doctor has been ordered to federal prison following his conviction on five
counts related to health care fraud. A jury deliberated for approximately three hours following a three-day trial
before convicting Dr. Dailey on March 30, 2016, of conspiracy to commit health care fraud, two counts of
false statements relating to health care matters, one count of conspiracy to pay and receive health care
kickbacks and one count of payment and receipt of health care kickbacks.
OnJuly 19, 2016, U.S. District Judge David Hittner, who presided over the trial, handed Dailey a 63-month
sentence. He was further ordered to pay restitution of $913,620. Dailey will also be required to serve a term of
three years of supervised release following completion of the prison term.
At trial, the jury heard that from approximately 2009 through 2012, Dailey was a physician specializing in
family practice in Houston and defrauded Medicare by authorizing Medicare beneficiaries for home health
care when such services were not needed. The evidence at trial demonstrated Dailey conspired with a home
health care owner in Houston and agreed to sign Medicare authorization forms certifying services in exchange
for a monthly flat fee from the home health owner. Dailey signed hundreds of authorization forms for
beneficiaries that would falsely certify the patients were homebound, that home health was medically
necessary and that the beneficiaries were under his care. Medicare paid the home health owner approximately
$913,620 for home health services Dailey referred.
Dailey will remain in custody pending transfer to a U.S. Bureau of Prisons facility to be determined in the near future.
Bristol-Myers Squibb to Pay $30 Million for Unlawful Kickbacks
Insurance Commissioner Dave Jones reported, in a press release, that the California Department of Insurance reached a $30 million on July
18, 2016 settlement with pharmaceutical giant Bristol-Myers Squibb over allegations of drug marketing fraud and physician kickbacks.
The settlement stems from charges in a whistleblower lawsuit filed by three former Bristol-Myers Squibb sales representatives. Insurance
Commissioner Jones joined the whistleblowers in the lawsuit.
“Patients have a right to expect medications prescribed for them are based solely on medical need and not because the physician was given
tickets to a sporting event or treated to a lavish golf outing,” said Insurance Commissioner Dave Jones. “Illegal and unethical marketing
practices put patient health at risk if a medical professional is influenced by the inducements offered by drug
makers.”
The whistleblower lawsuit alleged that Bristol-Myers Squibb violated the California Insurance Frauds
Prevention Act by employing and using sales representatives for the purpose of defrauding private
commercial health insurers by using kickbacks to procure patients or clients. The kickbacks were designed to
increase physician prescriptions of several drugs produced by Bristol-Myers Squibb including Pravachol,
used to lower cholesterol. As part of its alleged scheme, Bristol-Myers Squibb provided physicians and their
families with gifts and cash to induce physicians to increase prescriptions for Bristol-Myers Squibb products.
Enticements included:
•
Box suites at sporting events where physicians were provided tickets, food, drinks, and parking.
•
Enrollment in a Lakers basketball camp for doctors and their children.
•
Pre-paid golf outings at luxurious golf courses.
•
Tickets for physicians and their families to see Broadway plays in California cities.
•
Monetary incentives given to doctors responsible for prescription-drug decisions for formularies.
•
Lavish dinners, resort hotel trips, and concert tickets, given to doctors who were large-volume prescribers, to induce more prescriptions
in the future.
In addition to the $30 million payment, the settlement agreement with the insurance commissioner requires
Bristol-Myers Squibb to affirm its commitment to abiding by California laws regulating its sales
representatives’ interactions with doctors, including compliance with pertinent provisions of the California
Health and Safety Code and the California Insurance Frauds Prevention Act. Among other requirements,
Bristol-Myers Squibb is required to utilize a Comprehensive Compliance Program that is in accordance with
the Office of Inspector General’s “Compliance Program Guidance for Pharmaceutical Manufacturers.”
This whistleblower lawsuit was initially filed by former Bristol-Myers Squibb employees Michael Wilson and Lucius and Eve Allen, all of
whom are represented by the law firm of Waters Kraus & Paul in Los Angeles. Lucius Allen is a former Los Angeles Lakers basketball
player.
As required by the state’s insurance whistleblower law, Bristol-Myers Squibb’s settlement payment will be divided between the
whistleblowers and the State of California. The state will receive $14.1 million, to be used to enhance the investigation and prevention of
insurance fraud. Bristol-Myers Squibb did not admit to wrongdoing in the settlement agreement.
Insurers alleged to have been defrauded: Prudential, Cigna, Maxicare, Blue Cross/Blue Shield of California (name of entity at time lawsuit
was filed), HMSA Health Plan Hawaii, Scan Health Plus, United Health Plan, CalOptima, Argus, Merck-Medco, PCS, Prosever, Express
RX/Value RX/DPS, Caremark, MedImpact/MedCare, Envoy, Aetna Pharmacy Management, Pharmaceutical Care Net, Advance PCS, Rx
America, Prescription Solutions, WellPoint Pharmaceutical Management, First Health, Save-Rx, PacifiCare, and Health Net.
Medications in kickback scheme included: Plavix, Pravachol, Monopril, Abilify, Glucovance, Metaglip, Glucophage, Glucophage XR,
Cefzil, BuSpar, Serzone, Tequin, Pravigard, and Avapro.
Zalma Books from the American Bar Association
The Insurance Fraud Deskbook Barry Zalma, Esq., CFE, 2014 Paperback, 638 Pages, 7x10
The Insurance Fraud Deskbook is a valuable resource, peer reviewed by the American Bar Association, for those
who are engaged in the effort to reduce expensive and pervasive occurrences of insurance fraud. It explains the
elements of the crime and the tort to claims personnel, and it provides information for lawyers who represent
insurers so they can adequately advise their clients. Prosecutors and their investigators can use this book to
determine what is required to prove the crime and win their case.
The full text of decisions from courts of appeal and supreme courts across the country are provided so the reader
can understand what happens after the investigation is completed and can apply that information to undertake their
own thorough investigations. It allow claims personnel and their lawyers to understand what errors would cause a
defect or a not-guilty verdict.
The effort to reduce insurance fraud requires the assistance of both civil and criminal courts. The Insurance Fraud Deskbook can help the
prudent fraud investigator, insurance adjuster, insurance attorney, insurance Special Investigation Unit and insurance company
management to attain the information needed to deal with state investigators and prosecutor.
Available from the American Bar Association at:
http://shop.americanbar.org/eBus/Default.aspx?TabID=251&productId=214624; or [email protected], or 800-285-2221.
Diminution in Value Damages
How to Determine the Proper Measure of Damage to Real and Personal Property
This book was written to provide sufficient information to those who became interested in the issue since the
Georgia Supreme Court decided State Farm Mutual Automobile Insurance Co. v. Mabry, 274 Ga. 498, 556 S.E.2d
114 (Ga. 11/28/2001) and includes cases dealing with the use of diminution in value as a method of determining the
amount of loss incurred by a plaintiff seeking indemnity for damage to real or personal property.
Because confusion has reigned across the United States concerning the proper measure of damages for property
damage to property that has been repaired, Diminution In Value Damages assists the reader in answering the
questions concerning the proper measure of damage in each of the fifty United States and federal United States
jurisdictions
This edition has been totally rewritten and expanded, providing the most extensive and detailed coverage of the issue
and a thorough explanation of how to apply diminution in value damages to losses to property.
ISBN: 978-1-63425-295-8, Product Code: 5190524, 2015, 235 pages, 7 x 10, Paperback
Available at http://shop.americanbar.org/eBus/Store/ProductDetails.aspx?productId=203226972
Other Insurance Fraud Convictions
West Virginia Funeral Home Ordered to Reimburse Insurer for False Death Claims
Gatens-Harding Funeral Home owners Chad and Billie Harding were found by a federal judge that allowed
an insurance company in its case against the operators of a funeral home in Putnam County, West Virginia,
accused of filing false death claims on behalf of pre-need contract customers who weren’t actually dead.
Homesteaders Life Insurance Company was granted default judgment June 30.
The lawsuit said that the Hardings cashed in on over $1 million worth of pre-need funeral contracts for 111 people who were still alive
during an eight-year period.
The Hardings denied the allegations in a filing last year by their attorney Jeff Woods.
The judge cited a “complete lack of interest in defending” the case. The amount the Hardings will be ordered to pay Homesteaders hasn’t
yet been determined.
New Jersey Used Car Dealership Manager, Employees Plead Guilty in $1.4 Million Auto Loan Scam
Hector Marquez, the general manager of D.I.B Leasing in Teterboro, pleaded guilty to first-degree money laundering and second-degree
misconduct by a corporate official in a hearing before Superior Court Judge Susan Steele in Bergen County. Marquez also pleaded guilty to
second-degree insurance fraud in a separate indictment involving a $139,000 Bentley purchased at his dealership and later torched and
reported stolen to an insurance company.
The state has agreed to recommend a sentence not to exceed 16 years in the dealership case. In the insurance fraud case, the state has
agreed to recommend a sentence not to exceed seven years, to run concurrent to the first sentence. Marquez’s
sentencing is scheduled for Jan 20, 2017.
Marquez is the third defendant to plead guilty in the D.I.B. Leasing case. The dealership’s finance manager,
Paul Russo, pleaded guilty to second-degree money laundering and second-degree misconduct by a corporate
official. The state has agreed to recommend a prison term not to exceed 10 years, when Russo is sentenced on
September 16. The dealership’s title manager, Lisa Ghobrial, recently pleaded guilty to third-degree
misconduct by a corporate official. The state has agreed to recommend a three-year probationary term when she
is sentenced on September 16.
Prosecutors said the defendants created fake employment records, inflated incomes, and supplied false pay stubs
and fictitious employee verifications to dupe banks into approving auto financing for customers whose income
levels did not qualify them for loans on the pricey vehicles.
Four of the loans were taken out in the names of customers who had submitted personal information to apply for financing but ultimately
did not buy cars from the dealership, prosecutors allege. The fifth loan was in the name of a person who had never been to D.I.B. Leasing
or applied for a car loan there, prosecutors alleged.
The loan money obtained from the banks was for personal benefit by the various employees of the dealership, prosecutors said.
The remaining defendants have all been indicted on charges of conspiracy and money laundering in the first degree and with a
second-degree charge of trafficking in personal identifying information pertaining to another person:
•Patsy Galasso, owner of D.I.B. Leasing.
•Jennifer Perez, who assisted with loan applications.
•Michael Ricciardi, who did bookkeeping for the dealership.
Galasso and Ricciardi are also charged with second-degree identity theft, and 62 counts of theft by deception –
two in the second degree and 60 in the third degree. Galasso is also charged with second-degree misconduct by
a corporate official.
First degree crimes carry a sentence of 10 to 20 years in state prison and a criminal fine of up to $200,000; second-degree crimes carry a
sentence of five to 10 years in state prison and a criminal fine of up to $150,000; third-degree crimes carry a sentence of three to five years
in state prison and a criminal fine of up to $15,000.
Ten Years for Arson
Treiston Pierron, a 33-year-old Raceland, La., man was sentenced to 10 years in prison after pleading guilty to
arson in a fire that destroyed three homes last summer in Gheens, La.
Pierron pleaded guilty to three counts of simple arson for the house fires. He also pleaded guilty to one count of
aggravated arson for lighting a paper wick at the Lafourche Parish jail Dec. 26 and handing the wick to another
inmate, who allegedly set some paper and a blanket on fire.
The district attorney’s office says surveillance video captured the jail incident.
Pierron was set for trial this week.
He faced up to 15 years in prison on the simple arson charges and up to 20 years for the aggravated arson charge.
No Fault Schemer Sentenced to 25 Years in Prison
Michael Danilovich was sentenced to 25 years after he was convicted last year on for 16 counts of racketeering conspiracy, securities
fraud, health care fraud, mail fraud, wire fraud, and money laundering, said Preet Bharara, U.S. Attorney for the Southern District of New
York. He was sentenced by U.S. District Judge Deborah A. Batts, who presided over the trial. Prison resulted because of Danilovich’s role
in a $100 million automobile insurance fraud scheme, the largest such operation ever broken up by police in the United States, prosecutors
said.
The operation took advantage of the state’s no-fault auto insurance law, which requires prompt
reimbursement for medical treatment without the filing of a personal injury lawsuit, according to
Bharara. Under the law, patients can assign their right to reimbursement from an insurance
company to others, including medical clinics.
From 2007 through 2012, Danilovich’s organization defrauded automobile insurance companies
by creating and operating medical clinics — such as MRI offices, acupuncture and chiropractic
clinics — that provided unnecessary and excessive medical treatments.
The fraud was so extensive and wide ranging that Danilovich was the 36th defendant convicted in this case.
Unlicensed Insurance Agent Guilty of Grand Theft From Insurance Clients
Cristian Raul Videla, 34, of Van Nuys, pleaded no contest to one felony count of California Penal Code § 487(a), grand theft for
defrauding his customers by misrepresenting to them the amount of insurance coverage they purchased from him. Videla was originally
charged in June on five felony counts of grand theft. He surrendered to Department of Insurance detectives and bail was set at $100,000.
Investigators with the Department of Insurance Investigation Division discovered Cristian Videla assumed the
identity of a licensed insurance broker, sold cargo insurance to commercial truck drivers, misrepresented the amount
of coverage provided, and then pocketed a portion of the consumers’ premium for his own use.
Victims were unaware that Videla was providing less coverage than they paid for because he issued fraudulent
insurance certificates that indicated the victims had full coverage. The scheme was revealed after one of Videla’s
victims had a loss and was informed by the insurer that he did not have enough coverage and was responsible for the
remaining $50,000 of the $100,000 loss.
On July 18, 2016, Videla pleaded no contest and was convicted on one felony count of grand theft. He was sentenced
to five years’ probation, 120 hours of community service, and ordered to pay full restitution to his five victims. A
restitution hearing is set for August 30, 2016. This case is being prosecuted by the Los Angeles District Attorney’s
office.
Connecticut Man Admits to Role in Staging Car Crashes
Carlins Calixte of Norwich, a Connecticut man who authorities say conspired to stage about 50 car crashes in an insurance scheme
pleaded guilty to a federal charge. Calixte of Norwich entered the plea in New Haven to conspiracy to commit mail and wire fraud. He
faces up to 20 years in prison when he’s sentenced Sept. 30.
Federal authorities say 32-year-old Calixte and others conspired to stage car crashes in Connecticut to fraudulently collect insurance money
between 2011 and 2014. Many of the crashes were single-car incidents on remote roads with no witnesses other than the occupants of the
crashed vehicle.
Authorities say the defendants filed fraudulent property damage and injury claims with different car insurance companies. They then
collected payouts ranging from about $10,000 to $30,000 per incident.
Florida Woman Sentenced to 4 Years in BP Oil Spill Fraud Case
Caridad Rioseco Alejandrez, a Florida woman has been sentenced to four years in prison after filing a false claim in
connection with the 2010 oil spill in the Gulf of Mexico.
The U.S. Department of Justice said in a news release that 50-year-old Alejandrez has been sentenced to 48 months in
prison. She previously pleaded guilty to one count of mail fraud.
Her father was sentenced to a year in prison in connection with a similar case. Authorities say both filed fraudulent
claims against a fund created to reimburse people for costs and damages incurred after the BP well blowout.
Provides the Following Services to its Clients
•
Acting as a consultant or expert witness on behalf of insurers
and insureds in litigation.
•
Acting as a consultant to the insured in the presentation of a
first party claim.
•
•
•
Analysis of insurance litigation for the insurer and the insured.
•
Consultation with insurance claims personnel on methods to
avoid charges of bad faith.
•
Analysis of claims file material to allow the party to present
evidence to establish and document bad faith or the existence of
a genuine dispute between the insurer and insured.
Consultation with insurers and insureds on insurer compliance
with Fair Claims Practices laws and regulations.
•
Training on insurance and insurance law for all insurer Acting as
a mediator to help resolve insurance claims short of litigation.
Review of policy wording and claims files to determine if there
is a basis for payment or denial of a claim.
•
Analysis of insurance policy wording.
•
Litigation advice to defense or plaintiffs’ counsel.
Consultation from Zalma Insurance Consultants can save you or your client thousands of dollars in the defense or prosecution of an
insurance dispute. Zalma Insurance Consultants will find a solution to your insurance claims dispute that is fair, intelligent, beneficial and
Economical.
If you only need an opinion letter I will review your entire claim file and policy wording and prepare a coverage opinion letter for the flat
fee of $4,000.00. Otherwise, my services are billed at $500.00 per hour, portal to portal.
Zalma Insurance Consultants provides expert advice to counsel for insurers and plaintiffs’ counsel. Advice from Zalma Insurance
Consultants is indispensable to the resolution of insurance disputes. Consultation from Zalma Insurance Consultants can save you, your
counsel or client hundreds of hours of investigative and legal work. Call Barry Zalma at 310-390-4455 or e-mail at [email protected].
The EUO Is a Serious and Important Part of the Insurer’s Investigation
The attorney, insurance claims professional or investigator who conducts the Examination Under Oath (EUO) can take a role similar to the
role of a prosecutor without the usual constitutional restraints controlling testimony at a deposition
or trial. [Hickman v. London Assurance Corporation, 184 Cal. 524, 195 P. 45 (1920)] A false
statement as to any material fact during the EUO can cause the policy to be declared void, even if
the fact has no relationship to the loss.
In Claflin the false testimony concerned a witness that would not affect the amount payable under
the policy but to protect his reputation for veracity. The Supreme Court found that the witness of
the injury was material to the investigation and declared the policy void for fraud because he made
false statements under oath.
Contrary to the belief of lawyers for the insured, the EUO
is not an adversary proceeding like a deposition in a lawsuit.
The EUO is an investigative tool made available to the insurer. It allows the insurer to delve deeply
and under oath into all aspects of the policy and the loss. The testimony to be elicited is not
constrained by rules of discovery or the Codes of Civil Procedure.
The only restraint on the EUO is reasonableness. Unlimited questions are allowed. Only totally
irrelevant and unreasonable questions dealing with facts completely outside the policy, its
acquisition or the loss are not favored.
Irrelevant questions are tolerated if there is any possibility the question may lead to an inquiry about facts relevant to the policy or claim. In
fact, there are no questions that are irrelevant in an EUO since each question may lead to more important information that could never have
been learned about had not a foundation been laid by questions that appear, on their face, to be irrelevant. Since there are no rules for the
taking of the EUO any question asked is important and must be answered.
In Ram v. Infinity Select Ins., 807 F.Supp.2d 843 (2011), during the investigation of the insured’s claim, the plaintiff produced limited
records. Where an insurer has reason to suspect fraud in relation to a theft claim, inquiries into the insured’s financial status are relevant
and material, and a refusal to answer questions on that subject constitutes a material breach of the insurance contract.
Plaintiff refused to discuss his 2008 income at his EUO, and much of the income and employment information that he was
willing to provide throughout the investigation of his claim is admittedly false. The Court found that Plaintiff’s failure to
answer income questions constitutes a breach of the duty to cooperate, and no reasonable juror could find otherwise.
In Deguchi v. Allstate Ins. Co., Not Reported in F.Supp.2d, 2008 WL 1780271 (D.Hawai’I, 2008) a case where Plaintiffs’
testimony raised even more questions of possible motive, Plaintiffs prevented Allstate from further investigating and
determining coverage under the Policy. Specifically, Deguchi refused to submit to a further EUO, and Plaintiffs’ attorney
limited Scalas’ EUO to questions on the Princess Natasha, her loss, the two crew aboard her at the time of the loss, and
her value. Under the specific circumstances of this case, the court found that Allstate’s requests for EUOs were reasonable
as a matter of law. Deguchi, by refusing to allow a second EUO, and Scalas, by refusing to answer even basic questions, breached
Plaintiffs’ duty under the Policy to “submit to examinations under oath” as reasonably required by Allstate. Because Plaintiffs’ refusal
prevented Allstate from determining coverage under the Policy, Allstate had no duty to pay Plaintiffs under the Policy.
Similarly, in Powell v. United States Fid. & Guar. Co., 88 F.3d 271 (4th Cir.1996), the insureds’ home was destroyed by fire. Under their
homeowners’ insurance policy, the insureds were required to “submit to questions under oath and sign and swear to them.” Powell, 88 F.3d
at 272. During the EUO, the insureds refused to answer several questions and “to turn over financial and other documents,” claiming that
an EUO did not permit the insurer to “delve into financial or other information relating to the [insureds’] possible motives to intentionally
set the fire ... but ... [was] instead limited ... to an examination relating to the existence and extent of loss under the policy.” The United
States Court of Appeals for the Fourth Circuit disagreed, stating that an EUO “encompasses investigation into possible motives for
suspected fraud.” Concluding that the EUO “is not restricted to amount of loss, but the insurer has the right to examine the insured and his
witnesses as to any matter material to the insurer’s liability and the extent thereof.” Therefore, in Phillips v. Allstate Indemn. Co., 156
Md.App. 729, 848 A.2d 681 (2004) and Lindsey v. State Farm Fire and Cas. Co., Not Reported in F.Supp.2d, 2000 WL 1597763 (D.Md.,
2000) under the facts and circumstances of the case, the refusal to answer questions about his financial circumstances during the EUO
violated the terms of the policy and constituted a failure to cooperate.
In Michigan, in the context of a homeowner’s insurance policy, that the remedy for failing to comply with a requirement to submit to an
EUO is dismissal of the insured’s action. Thomson v. State Farm Ins. Co., 232 Mich.App. 38, 45, 592 N.W.2d
82 (1998); Yeo v. State Farm Ins. Co., 219 Mich.App. 254, 257, 555 N.W.2d 893 (1996). The court saw no
reason to distinguish between a valid EUO in a homeowner’s insurance policy and a valid EUO in a policy
providing uninsured motorist benefits. An insurance policy is much the same as any other contract; it is an
agreement between the parties. Because the no-fault statute does not require uninsured motorist benefits, there
is no public policy against enforcing the EUO provision in this context, and we must honor the intent of the
parties’ contract. [Cruz v. State Farm Mut. Auto. Ins. Co., 241 Mich.App. 159, 614 N.W.2d 689 (2000)].
The EUO Should Be Required by an Insurer:
#
When the insured has insufficient documentary evidence to prove his loss.
#
When the insured refuses to cooperate in the investigation of the insurer.
#
When the insured is unable to present documentary evidence in support of his or her claim.
#
When the Insured needs help proving his or her loss.
#
When the insurer has no other means of “cross examining” the proof of loss submitted by the insured.
#
When the insurer witnesses a fraudulent claim is being attempted.
The list of reasons for requiring an EUO are not the only reasons but a small list of potential reasons for an EUO.
When an insurance professional, whether an adjuster or a lawyer, finds a claim poses questions that cannot be answered by the usual and
common methods of investigating a claim, it is important to consider the use of the EUO to get the answers not available anywhere else.
Adapted from my e-book, “The Insurance Examination Under Oath” only available from Zalma Books at
http://www.zalma.com/zalmabooks.htm.
Zalma’s Insurance 101
Zalma Insurance Consultants and ClaimSchool Inc. have launched “Zalma’s Insurance 101,” a new online resource that provides videobased insurance training on http://www.zalma.com/videoblog/. Each educational video, which is about
three minutes each, offers free commentaries on insurance, insurance claims handling, and insurance
coverage.
Designed for people in the insurance business, whether they are working as an insurance agent, insurance
broker, insurance claims person or insurance lawyer, the video series teaches the basics and beyond. It
starts with a definition of insurance, moves through methods to read and understand an insurance policy,
and continues on to deal with the claim and use of investigative techniques.
Said Zalma, “It is my intent in creating these videos to provide anyone interested in insurance a means to painlessly learn everything there
is to know about property and casualty insurance in three-minute increments. If you start at Video Volume 1 and watch a new video every
day, three minutes a day, five days a week, you will have 12.5 hours of insurance education at the end of a year.”
There are now more than 400 videos with 3 to 5 new videos added every day. If you view, starting with the first video, one each day, five
days a week for 50 weeks you will have painlessly educated yourself without a need to prove you did so to a regulator, 12.5 hours of real
insurance education. The videos were adapted from my book, Insurance Claims: A Comprehensive Guide, available the National
Underwriter Company and is available at the Zalma Insurance Claims Library at
http://www.nationalunderwriter.com/reference-bookstore/property-and-casualty/zalma-insurance-claims-library.html.
Zalma’s Insurance Fraud Letter
© 2016 by Barry Zalma & ClaimSchool, Inc.
4441 Sepulveda Blvd, CULVER CITY CA 90230-4847
http://www.zalma.com # [email protected] # http://zalma.com/blog
ZIFL is made available by the publisher for educational purposes only as well as to give you general information and a general
understanding of the law, not to provide specific legal advice. By using ZIFL you understand that there is no attorney client relationship
between you and the publisher. ZIFL should not be used as a substitute for competent legal advice from a licensed professional attorney in
your state.
As readers of ZIFL are aware, Barry Zalma is an insurance coverage
consultant and expert witness. Mr. Zalma limits his practice to issues
involving coverage matters, providing consultation to insurers, those in
the business of insurance, policyholders and their counsel. Mr. Zalma has
qualified as an expert in various state and federal courts across the U.S.
and as far away as the British Cayman Islands.
The comments made in each issue of ZIFL are for information only and
are not intended as legal advice. If you need legal advice, contact a local
attorney. If you need an insurance claims handling, insurance coverage or
insurance bad faith consultant and expert testimony contact Mr. Zalma at Zalma Insurance
Consultants, 310-390-4455 or e-mail to [email protected]. Has this email been forwarded to
you by a colleague? Register with Zalma’s Insurance Fraud Letter at this link. to receive the
latest news directly to your inbox regularly.

Published in Adobe pdf format effective August 1, 2016

Transcription

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