Why Some People Believe Insurance Fraud is not
Criminal & Nobody’s Been Hurt
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Posted on May 13, 2022 by Barry Zalma
See the full video at https://rumble.com/v14h8gs-true-crime-of-insurance-fraud-video-number-73.html and at
Dr. Scrooge was eighty-five-years old. He lived with his daughter and son-in-law in a remodeled tract home outside of Portland, Oregon.
The doctor’s daughter had insisted that he move into her house, even though he owned one of his own, after his last heart attack. She was afraid that her father, now a widower, would succumb to his passion for chocolate fudge ice cream.
Only two months before he moved to his daughter’s house Dr. Scrooge managed to consume a full gallon of chocolate fudge ice cream at a single sitting. Shortly after that, as any healthy person under the same circumstances would, Dr. Scrooge felt serious pain in his chest.
There was no question that Dr. Scrooge had a heart condition. It was, however, a condition that could be controlled by medication.
After moving in with his daughter, Dr. Scrooge signed an agreement with a health maintenance organization who promised him no premium and better services than Medicare. Always on a look out for a bargain, Dr. Scrooge was pleased with the plan even though it did not pay 100% of all his pharmacy charges. He had many drug samples in his house given to him by drug-salesmen. He did not expect to ever need to buy a drug. He happily filled his own prescriptions for the medication his cardiologist prescribed to keep him healthy.
Dr. Scrooge’s son-in-law was a detective with the Bunco-Forgery Division of the Portland Police Department. The Portland police provided its officers with an excellent preferred provider health plan. They could use any doctor they desired and were only required to pay $5 for every prescription drug they purchased regardless of the true cost of the drug. Dr. Scrooge’s HMO required a payment of up to $25 per prescription, depending on the cost of the drug.
Since he lived with them, Dr. Scrooge (although he did not actively practice) still maintained his medical license. He would, at the request of his daughter, write prescriptions for antibiotics and other benign drugs requested for the assistance of the family. Occasionally he would even go to the drug store and pick up the drugs for the family as long as his daughter gave him a $5 bill for the pharmacist.
Dr. Scrooge’s cardiologist was well read. He prescribed only the most recent and most effective heart medications. The drugs he prescribed, because they were new, and no generic variations were yet on the market, were extremely expensive. Much to the shock of Dr. Scrooge they were also so new that he had none in his supply of drug samples. The drug salesmen knew he was retired and refused to provide him with any further samples.
Five months after Dr. Scrooge started his plan of saving on prescription drugs, the detective was called into his captain’s office.
“When was your last physical?”
“About a year ago, Captain. Why do you ask?”
“I’m concerned about your health, Wilson.”
“No reason, Captain, my health is perfect. The doctor gave me a clean bill and said that I had cholesterol levels equal to a person ten years younger than me.”
“He did, did he. Wilson, do you use a doctor named Scrooge?”
“Well, I don’t really use him as my physician. He lives in my house. He’s my father-in-law.”
“Wilson, I have a report here from our health insurance administrator telling me that Dr. Scrooge has written prescriptions for blood thinners, blood pressure mediation, diuretics and nitroglycerin, in your name. These drugs are only prescribed for people with a serious heart condition. Are you taking those drugs?”
“Dad, have you been writing prescriptions for your heart medicine in my name?”
“Yes.”
“Why?”
“Because they only cost $5 on your insurance plan, and they cost $25 on mine.”
“Don’t you remember what I do for a living? Have you no idea what you have done? You have committed fraud in my name!”
“But no one was hurt, the insurance company pays these bills all the time.”
Wilson, the next day, was forced to speak to his captain and inform him that his father-in-law had attempted to save some money on his own insurance by making his prescriptions out in Wilson’s name. He convinced the Captain that, although technically the old man had committed a crime, it would serve no purpose to put him in prison at his advanced age. It might even please the old man because, in prison, he would get the medicine for free.
Wilson’s record was noted, his next promotion was delayed by twelve months. His father-in-law refused to fill his own prescriptions and pay the extra $20. Because he did not have the medication to take, he had a real heart attack and was hospitalized for three weeks.
Dr. Scrooge still believes that no one is hurt by insurance fraud.
(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].
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Concealing a Weapon Used in a Murder is an Intentional & Criminal Act
Post 5002
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In Howard I. Rosenberg; Kimberly L. Rosenberg v. Chubb Indemnity Insurance Company Howard I. Rosenberg; Kimberly L. Rosenberg; Kimberly L. Rosenberg; Howard I. Rosenberg v. Hudson Insurance Company, No. 22-3275, United States Court of Appeals, Third Circuit (February 11, 2025) the Third Circuit resolved whether the insurers owed a defense for murder and acts performed to hide the fact of a murder and the murder weapon.
FACTUAL BACKGROUND
Adam Rosenberg and Christian Moore-Rouse befriended one another while they were students at the Community College of Allegheny County. On December 21, 2019, however, while at his parents’ house, Adam shot twenty-two-year-old Christian in the back of the head with a nine-millimeter Ruger SR9C handgun. Adam then dragged...
Renewal Notices Sent Electronically Are Legal, Approved by the State and Effective
Post 5000
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Washington state law allows insurers to deliver insurance notices and documents electronically if the party has affirmatively consented to that method of delivery and has not withdrawn the consent. The Plaintiffs argued that the terms and conditions statement was not “conspicuous” because it was hidden behind a hyperlink included in a single line of small text. The court found that the statement was sufficiently conspicuous as it was bolded and set off from the surrounding text in bright blue text.
In James Hughes et al. v. American Strategic Insurance Corp et al., No. 3:24-cv-05114-DGE, United States District Court (February 14, 2025) the USDC resolved the dispute.
The court’s reasoning focused on two main points:
1 whether the ...
Rescission in Michigan Requires Preprocurement Fraud
Post 4999
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Lie About Where Vehicle Was Garaged After Policy Inception Not Basis for Rescission
This appeal turns on whether fraud occurred in relation to an April 26, 2018 renewal contract for a policy of insurance under the no-fault act issued by plaintiff, Encompass Indemnity Company (“Encompass”).
In Samuel Tourkow, by David Tourkow v. Michael Thomas Fox, and Sweet Insurance Agency, formerly known as Verbiest Insurance Agency, Inc., Third-Party Defendant-Appellee. Encompass Indemnity Company, et al, Nos. 367494, 367512, Court of Appeals of Michigan (February 12, 2025) resolved the claims.
The plaintiff, Encompass Indemnity Company, issued a no-fault insurance policy to Jon and Joyce Fox, with Michael Fox added as an additional insured. The dispute centers on whether fraud occurred in...
Insurance Fraud Leads to Violent Crime
Post 4990
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CRIMINAL CONDUCT NEVER GETS BETTER
In The People v. Dennis Lee Givens, B330497, California Court of Appeals, Second District, Eighth Division (February 3, 2025) Givens appealed to reverse his conviction for human trafficking and sought an order for a new trial.
FACTS
In September 2020, Givens matched with J.C. on the dating app “Tagged.” J.C., who was 20 years old at the time, had known Givens since childhood because their mothers were best friends. After matching, J.C. and Givens saw each other daily, and J.C. began working as a prostitute under Givens’s direction.
Givens set quotas for J.C., took her earnings, and threatened her when she failed to meet his demands. In February 2022, J.C. confided in her mother who then contacted the Los Angeles Police Department. The police ...
Police Officer’s Involvement in Insurance Fraud Results in Jail
Post 4989
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Von Harris was convicted of bribery, forgery, and insurance fraud. He appealed his conviction and sentence. His appeal was denied, and the Court of Appeals upheld the conviction.
In State Of Ohio v. Von Harris, 2025-Ohio-279, No. 113618, Court of Appeals of Ohio, Eighth District (January 30, 2025) the Court of Appeals affirmed the conviction.
FACTUAL BACKGROUND
On January 23, 2024, the trial court sentenced Harris. The trial court sentenced Harris to six months in the county jail on Count 15; 12 months in prison on Counts 6, 8, 11, and 13; and 24 months in prison on Counts 5 and 10, with all counts running concurrent to one another for a total of 24 months in prison. The jury found Harris guilty based on his involvement in facilitating payments to an East Cleveland ...
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To Dispute an Arbitration Finding Party Must File Dispute Within 20 Days
Post 4988
EXCUSABLE NEGLECT SUFFICIENT TO DISPUTE ARBITRATION LATE
In Howard Roy Housen and Valerie Housen v. Universal Property & Casualty Insurance Company, No. 4D2023-2720, Florida Court of Appeals, Fourth District (January 22, 2025) the Housens appealed a final judgment in their breach of contract action.
FACTS
The Housens filed an insurance claim with Universal, which was denied, leading them to file a breach of contract action. The parties agreed to non-binding arbitration which resulted in an award not
favorable to the Housens. However, the Housens failed to file a notice of rejection of the arbitration decision within the required 20 days. Instead, they filed a motion for a new trial 29 days after the arbitrator’s decision, citing a clerical error for the delay.
The circuit court ...
