This Isn’t Fraud, I’m Just Getting a Lower Premium
Read the full article at https://www.linkedin.com/pulse/true-crime-insurance-fraud-video-number-44-barry-zalma-esq-cfe and see the full video at https://rumble.com/vytsi0-true-crime-of-insurance-fraud-video-number-44.html?mref=6zof&mrefc=3 and at
and at https://zalma.com/blog plus more than 4150 posts.
Posted on March 29, 2022 by Barry Zalma
See the full video at https://rumble.com/vytsi0-true-crime-of-insurance-fraud-video-number-44.html?mref=6zof&mrefc=3 and at
Barry Zalma, Esq., CFE presents videos so you can learn how insurance fraud is perpetrated and what is necessary to deter or defeat insurance fraud. This Video Blog of True Crime Stories of Insurance Fraud with the names and places changed to protect the guilty are all based upon investigations conducted by me and fictionalized to create a learning environment for claims personnel, SIU investigators, insurers, police, and lawyers better understand insurance fraud and weapons that can be used to deter or defeat a fraudulent insurance claim.
Insurance Premium Fraud
Insurance fraud is not limited to fake claims. Most people don’t present claims. The basic principle upon which insurance is based require the many to pay small amounts so that the few can collect. If the risk is not spread fairly among the many, all suffer.
Most businessmen would be shocked at a suggestion that they inflate a claim. They are honest in their business dealings. They honor their contracts and pay their bills. They seldom have insurance claims. When they have a claim, they deal fairly and honorably with their insurer.
Paying insurance premiums hurt. The marketplace is competitive. Prices vary from insurer to insurer. Skills vary from insurance broker to insurance broker.
Eventually, businessmen learn how insurers set their premiums. They know that rates are applied to modifiers like the square footage of the structure, the payroll, or the gross receipts of the business.
A businessman, sitting with his insurance broker, asks how he can get the lowest premium. He will often put his morality on hold when the broker suggests that he estimate a lower amount of gross earnings. The businessman will see nothing wrong with loping 10,000 square feet of his 50,000-square foot warehouse when applying for insurance. When called upon to list the payroll for his workers’ compensation policy, he will be unconcerned when he tells his broker the payroll is $200,000 less than it actually is. It is just good business sense to reduce your workers’ compensation premium. When his policy shows factory workers cost more to insure than clerical, he “accidentally” reports to his workers’ compensation insurer that ten percent of his employees are factory workers and ninety percent are clerical, although the opposite is true.
What the businessman does not know, and what his broker does not tell him, is that knowingly misrepresenting a material fact [and there is nothing more material to an insurer than the basis upon which the premiums are calculated] is fraud. Insurance fraud in the acquisition of insurance bears both civil and criminal penalties.
An insurance broker who aids or abets and insured in obtaining lower premiums based upon false information is equally guilty of fraud. The agent or broker who does not require the insured to sign an application will find, if the fraud is discovered, that the insured will deny knowledge of the application. He will merely say, “I trusted my broker. My records were obvious in my office. All he had to do was ask and I would have told him the truth.”
The broker, faced with such a situation, will find himself defending lawsuits brought by the insured and the insurer.
The California Insurance Code now requires the following warning on all claims documents presented to insureds by insurers:
FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM
ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
I believe, to protect the insured, the broker and the insurer, that the law should be modified to require the same warning on every application for insurance. A warning will not stop a person intent on committing fraud. It will, however, remind the honest businessman tempted to commit fraud to obtain a lower premium of the hazards of his actions.
Insurance fraud is not limited to fake claims. Most people don’t present claims. The basic principle upon which insurance is based require the many to pay small amounts so that the few can collect. If the risk is not spread fairly among the many, all suffer.
What the businessman does not know, and what his broker does not tell him, is that knowingly misrepresenting a material fact [and there is nothing more material to an insurer than the basis upon which the premiums are calculated] is fraud. Insurance fraud in the acquisition of insurance bears both civil and criminal penalties.
Every claim adjuster and investigator should review every word on the application and obtain the insured’s answers asked as if the adjuster has no knowledge of the answers on the application form or be criticized for not completing a thorough investigation.
(c) 2022 Barry Zalma & ClaimSchool, Inc.
Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He practiced law in California for more than 44 years as an insurance coverage and claims handling lawyer and more than 54 years in the insurance business. He is available at http://www.zalma.com and [email protected].
Over the last 54 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created a library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.
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Write to Mr. Zalma at [email protected]; http://www.zalma.com; http://zalma.com/blog; I publish daily articles at https://zalma.substack.com, Go to the podcast Zalma On Insurance at https://anchor.fm/barry-zalma; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/
Detail Charging Defendant for Fraud is Sufficient
Post 5242
Read the full article at https://lnkd.in/g_HVw36q, see the video at https://lnkd.in/gpBd-XTg and at https://lnkd.in/gzCnBjgQ and at https://zalma.com/blog plus more than 5200 posts.
Charges that Advises the Defendant of the Crime Cannot be Set Aside
In United States Of America v. Lourdes Navarro, AKA Lulu, No. 25-661, United States Court of Appeals, Ninth Circuit (December 4, 2025) Lourdes Navarro appealed the district court’s denial of her motion to dismiss the indictment and enter final judgment was in error.
FACTUAL BACKGROUND
The indictment alleged that insurers reimburse only for medically necessary services. Navarro performed unnecessary respiratory pathogen panel (RPP) tests on nasal swabs collected from asymptomatic individuals for COVID-19 screening.
Navarro billed over $455 million to insurers for those additional RPP tests that she knew to be medically unnecessary. These allegations constituted a plain, concise, and definite written ...
Louisiana Statute Prevents Enforcement of Contract Term Requiring Arbitration of Disputes
Post 5241
Read the full article at https://www.linkedin.com/pulse/international-convention-requiring-enforcement-award-barry-sttdc, see the video at and at and at https://zalma.com/blog plus more than 5200 posts.
In Town of Vinton v. Indian Harbor Insurance Company, Nos. 24-30035, 24-30748, 24-30749, 24-30750, 24-30751, 24-30756, 24-30757, United States Court of Appeals, Fifth Circuit (December 8, 2025) municipal entities including the Town of Vinton, et al sued domestic insurers after dismissing foreign insurers with prejudice. The insurers sought arbitration under the Convention on the Recognition and Enforcement of Foreign Arbitral Awards (the “Convention”) but the court held Louisiana law — prohibiting arbitration clauses in such policies—controls, as the Convention does not apply absent foreign parties who ...
Refusal to Provide Workers’ Compensation is Expensive
Post 5240
Read the full article at https://lnkd.in/guC9dnqA, see the video at https://lnkd.in/gVxz-qmk and at https://lnkd.in/gUTAnCZw, and at https://zalma.com/blog plus more than 5200 posts.
In Illinois Department of Insurance, Insurance Compliance Department v.USA Water And Fire Restoration, Inc., And Nicholas Pacella, Individually And As Officer, Nos. 23WC021808, 18INC00228, No. 25IWCC0467, the Illinois Department of Insurance (Petitioner) initiated an investigation after the Injured Workers’ Benefit Fund (IWBF) was added to a pending workers’ compensation claim. The claim alleged a work-related injury during employment with the Respondents who failed to maintain workers’ compensation Insurance.
Company Overview:
USA Water & Fire Restoration, Inc. was incorporated on January 17, 2014, and dissolved on June 14, 2019, for failure to file annual reports and pay franchise taxes. It then operated under assumed names including USA Board Up & Glass Co. and USA Plumbing and Sewer. The business ...
The Professional Claims Handler
Post 5219
Posted on October 31, 2025 by Barry Zalma
An Insurance claims professionals should be a person who:
Can read and understand the insurance policies issued by the insurer.
Understands the promises made by the policy.
Understand their obligation, as an insurer’s claims staff, to fulfill the promises made.
Are competent investigators.
Have empathy and recognize the difference between empathy and sympathy.
Understand medicine relating to traumatic injuries and are sufficiently versed in tort law to deal with lawyers as equals.
Understand how to repair damage to real and personal property and the value of the repairs or the property.
Understand how to negotiate a fair and reasonable settlement with the insured that is fair and reasonable to both the insured and the insurer.
How to Create Claims Professionals
To avoid fraudulent claims, claims of breach of contract, bad faith, punitive damages, unresolved losses, and to make a profit, insurers ...
The History Behind the Creation of a Claims Handling Expert
The Insurance Industry Needs to Implement Excellence in Claims Handling or Fail
Post 5210
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry. This statement of my philosophy on claims handling starts with my history as a claims adjuster, insurance defense and coverage lawyer and insurance claims handling expert.
My Training to be an Insurance Claims Adjuster
When I was discharged from the US Army in 1967 I was hired as an insurance adjuster trainee by a professional and well respected insurance company. The insurer took a chance on me because I had been an Army Intelligence Investigator for my three years in the military and could use that training and experience to be a basis to become a professional insurance adjuster.
I was initially sat at a desk reading a text-book on insurance ...
The History Behind the Creation of a Claims Handling Expert
The Insurance Industry Needs to Implement Excellence in Claims Handling or Fail
Post 5210
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry. This statement of my philosophy on claims handling starts with my history as a claims adjuster, insurance defense and coverage lawyer and insurance claims handling expert.
My Training to be an Insurance Claims Adjuster
When I was discharged from the US Army in 1967 I was hired as an insurance adjuster trainee by a professional and well respected insurance company. The insurer took a chance on me because I had been an Army Intelligence Investigator for my three years in the military and could use that training and experience to be a basis to become a professional insurance adjuster.
I was initially sat at a desk reading a text-book on insurance ...
