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

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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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