Zalma’s Insurance Fraud Letter – June 15, 2022
ZIFL Volume 26 Issue 12
Read the full article at https://lnkd.in/gmxiSdAx
Zalma’s Insurance Fraud Letter Contains articles on the following subjects in great detail at ZIFL-06-15-2022. The following are some of the articles available with the full 20 pages available at https://lnkd.in/gaHvyTJA
Insurance Fraud & the States
State insurance departments near the turn of the century recognized that insurance fraud is a serious crime taking multiple billions of dollars from the insurance industry. Local police and prosecutors were not concerned, even after insurance fraud was made a felony, because no one suffered physical injury or death. Insurance fraud just cost a lot of money to insurers who were perceived as extremely wealthy and more victimizers than victim.
Since almost no one was being prosecuted for insurance fraud states, like California, enacted statutes that required insurers to thoroughly investigate all claims, institute a special fraud investigation unit whose only purpose was to detect, investigate, gather evidence, and present that evidence to prosecutors to prosecute the crime. The Special Investigation Units (SIU) did the work only to find most of their investigations ignored and their successes received little or no encouragement from the insurers and the state. Both wanted all claims settled quickly and fairly. The sales people could not explain why their fraud perpetrator clients were being placed under oath and asked to prove their loss rather than just receive a quick and unquestioned check.
Reporting On an Accusation of Insurance Fraud Results in Defamation Suit
Fair Report Privilege Protects Reports of Insurance Fraud
Fox Television Stations, LLC (Fox), William Melugin, Daniel Leighton, and Kris Knutsen (collectively, the Fox defendants) appealed from orders denying their special motions to strike (Code Civ. Proc., § 425.16; anti-SLAPP statute) the complaint filed by Dr. Jay W. Calvert, a nationally recognized plastic surgeon, and Jay Calvert, M.D., Professional Corporation (the professional corporation) (collectively, the Calvert plaintiffs). In Jay W. Calvert et al. v. Fox Television Stations, LLC et al., B310772, California Court of Appeals, (May 25, 2022) the Court of Appeal reversed the trial court’s decision.
Person Accused of Fraud Failed to Promptly File Dispositive Motion
Provider To PIP Insured Not a Party to Contract
Plaintiffs Hartford Accident and Indemnity Company, Property & Casualty Ins. Company of Hartford, Trumbull Insurance Company, and Twin City Fire Insurance Company (together, “Hartford”) claim that Defendant Greater Lakes Ambulatory Surgical Center LLC submitted fraudulent claims for no-fault benefits for treatment of individuals who were in auto accidents. Hartford asserts claims of fraud, silent fraud, and unjust enrichment.
In Hartford Accident and Indemnity Company, et al. v. Greater Lakes Ambulatory Surgical Center LLC, No. 18-cv-13579, United States District Court, E.D. Michigan, Southern Division (May 26, 2022) Greater Lakes moved for leave to file a motion for judgment on the pleadings under Federal Rule of Civil Procedure 12(c), arguing that Hartford’s tort claims must be dismissed because the parties’ relationship is governed by contract.
Health Insurance Fraud Convictions
Osteopathic Physician Admits Illegally Prescribing Drug
Matthew Steven Miller, 43, pleaded guilty in front of U.S. District Judge Ronnie L. White to one count of obtaining a controlled substance by fraud and one count of making a false statement concerning a health care matter.
Miller, an osteopathic physician from Collinsville, Illinois pleaded guilty in U.S. District Court and admitted illegally prescribing an anti-anxiety drug.
Miller admitted illegally writing prescriptions for the anti-anxiety drug Xanax for six people between 2016 and 2018. He did not have a doctor-patient relationship with them, had not examined them, had not determined that they needed the drug and did not document the prescriptions, his plea agreement says. On some occasions, they sold the drugs and split the money with Miller, his plea says.
Miller wrote the prescriptions despite not being licensed by Missouri’s Bureau of Narcotics and Dangerous Drugs and lacking a Drug Enforcement Administration registration number necessary to do so.
Miller was licensed to practice medicine in Missouri, Michigan and New Jersey.
Other Insurance Fraud Convictions
Jacksonville Contractor Pleads Guilty to Felony Home Repair Fraud
Clint A. Stevens, 45, the owner of a Jacksonville construction company pleaded guilty to home repair fraud May 24, 2022 in Morgan County Court.
Stevens, the owner of C&A Construction, pleaded guilty to home repair fraud, a Class 4 felony. The single charge stems from an arrest by Jacksonville Police on April 12th, 2021 after an investigation.
According to the charges, Stevens misrepresented material facts relating to terms of a contract or promised performance, saying September 28, 2020 that he would start repairs on a home on Pintail Court by October 2020 and then didn’t initiate the work.
Underwriting & Rescission
Rescission as a Weapon Against Insurance Fraud
Since the turn of the century the plaintiffs’ bar has attempted to defeat the remedy of rescission and allow their clients more access to courts of law assessing damages against insurers and avoid equity courts who, if rescission was established, would have no right to damages at law. The plaintiff’s bar created the concept of “post loss underwriting” (an oxymoron) to convince a court that the insurer did not use the remedy of rescission properly and force the insurer to pay a claim on a policy issued by deception even when the attempts to get damages from an insurer that has established all of the elements needed to prove the right to rescission.
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The Professional Claims Handler
Post 5218
Read the full article at https://www.linkedin.com/pulse/zalma-philosophy-claims-handling-part-8-barry-zalma-esq-cfe-zdwsc, see the full video at https://rumble.com/v70zl4s-the-zalma-philosophy-of-claims-handling-part-8.html and at https://youtu.be/MIYcF71ffRQ, and at https://zalma.com/blog plus more than 5200 posts.
Claims Commandment X – Thou Shall Not Pretend to be a Lawyer
Some experienced and professional claims people know the law in their area of expertise better than most lawyers.
Adjusters should be adjusters and leave lawyering to lawyers. Similarly, lawyers should be lawyers and never try to be adjusters.
Claims Commandment XI – Thou Shall Empathize With the Claimant
Everyone presenting a claim is unhappy, disturbed, shocked, injured and needs help.
Empathy is identification with and understanding of another’s situation, feelings, and motives. It is the ability to understand another person’s circumstances, point of view, thoughts, and feelings....
HOW TO CREATE AN EXCELLENCE IN CLAIMS HANDLING PROGRAM
See the full video at https://rumble.com/v70wb2i-the-zalma-philosophy-of-claims-handling-part-6.html and at https://youtu.be/tL5nDKPEs40 and at https://zalma.com/blog plus more than 5200 posts.
Post 5217
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.
An Excellence in Claims Handling program begins with a statement in the insurer’s claims manual or statement of professionalism that it is dedicated to providing excellence in claims handling to every insured who presents a claim.
The excellence in claims handling program should include, at a minimum:
A series of lectures supported by text materials explaining:
A definition of insurance.
How to read and understand an insurance policy.
How to interview an insured, witness, or claimant.
How to assist an insured in the insured’s obligation to ...
The Professional Claims Handler
Post 5216
Read the full article at https://www.linkedin.com/pulse/zalma-philosophy-claims-handling-part-5-barry-zalma-esq-cfe-jde8c, see the full video at https://rumble.com/v70q4x8-the-zalma-philosophy-of-claims-handling-part-5.html and at https://youtu.be/6b9tZQsEkB4, and at https://zalma.com/blog plus more than 5200 posts.
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.
Standards to be a Professional Claims Adjuster
The Insurance claims professional should be a person who:
1. Can read and understand the insurance policies issued by the insurer.
2. Understands the promises made by the policy.
3. Understand their obligation, as an insurer’s claims staff, to fulfill the promises made.
4. Are competent investigators.
5. Have empathy and recognize the difference between empathy and sympathy.
6. ...
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 ...
