Zalma on Insurance
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Insurance Claims professional presents articles and videos on insurance, insurance Claims and insurance law for insurance Claims adjusters, insurance professionals and insurance lawyers who wish to improve their skills and knowledge. Presented by an internationally recognized expert and author.
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September 01, 2022
Zalma’s Insurance Fraud Letter – September 1, 2022

ZIFL - Volume 26, Issue 17 – September 1, 2022

Posted on September 1, 2022 by Barry Zalma

The issue, available as a 25 page .pdf document here ZIFL-09-01-2022

See the full video at https://rumble.com/v1i44c7-zalmas-insurance-fraud-letter-september-1-2022.html and at

The issue includes articles including:
Public Adjuster Firm Accused of Pocketing $600,000 in Insurer Payouts in 2 States

Andrew Joseph Mitchell, according to the Texas Department of Insurance, who reported that a public adjusting firm that was sanctioned last month by Louisiana regulators has pocketed more than $300,000 in insurer payouts intended for Texas property owners.
Michigan Allows Fraudster to Receive PIP Benefits but no UM/UIM Benefits

Plaintiff appealed the trial court’s order granting summary disposition in favor of defendants Home-Owners Insurance Company (“Home-Owners”), American Country Insurance Company (ACIC), and Hartford Accident and Indemnity Company (“Hartford”), with respect to plaintiff’s claims for uninsured or underinsured motorist benefits and first-party personal protection insurance (PIP) benefits under the no-fault act, MCL 500.3101 et seq. Although defendants disputed their priority to pay PIP benefits, the trial court did not decide the priority issue, but instead dismissed all claims on the basis of antifraud provisions in defendants’ respective policies.

In Jonathan Jones v. Home-Owners Insurance Company, American Country Insurance Company, And Hartford Accident & Indemnity Company, and Sharneta Henderson, No. 355118, Court of Appeals of Michigan (August 18, 2022) the Court of Appeal produced a Solomon-like decision.
The Law Applies to Thee but not to Me – Insurance Fraud Pays in New York

Oneatha Swinton, the former acting principal of Port Richmond High school in Staten Island, New York, convicted of car insurance fraud kept her employment with the New York Department of Education – and even got a raise – despite what school investigators called her “pattern of dishonesty.”

The DOE gave Swinton, a deal to stay on despite the criminal conviction plus findings that she improperly funneled $100,000 in school funds to a vendor, and “failed to safeguard” 600 DOE computers, printers and laptops which vanished under her watch.
California Claims Regulations

Fair Claims Settlement Practices Regulations 2022

If You Haven’t Complied by Today You are in Violation

Insurers licensed or operating in California must ascertain that their entire claims staff has read, understood or be trained about the California Fair Claims Settlement Practices Regulations by September 1 of Each Year and be ready to swear under oath that the Regulation has been complied with by the insurer.
Before Electing to Rescind
Bases for Rescission

The primary bases for rescission are:

misrepresentation or material fact(s),

concealment of material fact(s),

mistake of material fact(s),

mistake of law, or

fraud.

New York StateWide Senior Action Council Announces It’s Medicare Fraud of the Month
Telemedicine Fraud.

“Telemedicine Fraud, often called Telehealth Fraud is a growing trend in Medicare. The COVID-19 pandemic created unprecedented challenges for how patients accessed health care with the need for social isolation leading to an explosion in remote Telemedicine care,” stated Maria Alvarez, Executive Director of StateWide in announcing this month’s Medicare Fraud of the Month.

The StateWide Fraud of the Month is a component of the Senior Medical Patrol, the definitive resource for New York State’s senior citizens and caregivers to help detect, prevent, and report Medicare fraud and waste. StateWide is New York’s grantee/administrator for this Federal Program.
Good News From the Coalition Against Insurance Fraud

Ricky Gonzales ran Ricky’s Construction Company, which supplied construction labor for contractors. The Tampa, Fla.-area man lied he paid workers’ compensation for the laborers he provided — who were undocumented immigrants. The contractors then sent Gonzales what they thought were payroll checks. Gonzales cashed the checks at banks to pay the workers. Gonzales lied that employees had full worker’s comp. In truth, he received and cashed more than $7M of checks from construction contractors for his employees. That far exceeded the limited payroll that Gonzales reported to his comp insurer. His employees thus worked at job sites without adequate insurance coverage. The insurers lost premiums they would’ve charged had they known the true number of workers their policies were being manipulated to cover. Gonzalez also illegally avoided state and federal payroll taxes. He pled federally guilty and faces up to 25 years in prison when sentenced.

And many more convictions.
Health Insurance Fraud Convictions
South Bay Chiropractor Sentenced to Prison for Receiving Kickbacks

A Redondo Beach chiropractor was sentenced to 14 months in prison for soliciting kickbacks from other hospitals. (Shutterstock)

Brian Carrico, 68, of Redondo Beach, was sentenced August 26, 2022 to 14 months in federal prison by U.S. District Judge Josephine L. Staton, who also ordered him to pay a fine of $25,000.

The South Bay chiropractor was sentenced for taking kickbacks from Pacific Hospital — a medical center in Long Beach whose then-owner was later imprisoned — and for soliciting kickbacks from another Southern California hospital. Carrico pleaded guilty in February to one count of soliciting kickbacks — the same day his two Redondo Beach-based companies, Performance Medical & Rehab Center Inc. and One Accord Management Inc. — each pleaded guilty to one count of conspiracy to solicit kickbacks.

And dozens more convictions.
Zalma on Insurance at Locals.com
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Florida Sting Operation Busted 13 Contractors Without Workers’ Comp

In an attempt to save the few remaining insurers doing business in Florida, the state has taken aim at unlicensed contractors who some claim have increased the cost of repair to property in Florida.
Other Insurance Fraud Convictions
Florida Staffing Firm Head Sentenced to 24 Years for Off-Book Labor Scheme

Mykhaylo Chugay from 2007 to 2021 according to federal prosecutors said, operated a number of shady staffing companies in south Florida that avoided paying more than $25 million in federal taxes. Last week, a federal judge sentenced Chugay to 24 years in prison for his June conviction on crimes that included fraud, harboring illegal aliens and money laundering, according to prosecutors and news reports. Plus many more convictions.
Insurance Fraud in the U.K.
On August 25, 20200 the Association of British Insurers and the Insurance Fraud Bureau Announced:

The number and cost of fraudulent claims fell in 2021, but the average scam uncovered at a record level of over £12,000.

Motor insurance claim fraud still the most common insurance con.

Barry Zalma, Esq., CFE

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 also serves as an arbitrator or mediator for insurance related disputes. 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 the following library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.

Barry Zalma, Inc., 4441 Sepulveda Boulevard, CULVER CITY CA 90230-4847, 310-390-4455;

Subscribe to Zalma on Insurance at locals.com https://zalmaoninsurance.local.com/subscribe. Subscribe to Excellence in Claims Handling at https://barryzalma.substack.com/welcome. Write to Mr. Zalma at [email protected];

http://www.zalma.com

; http://zalma.com/blog; I publish daily articles athttps://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

00:13:31
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What else you may like…
Videos
Posts
21 hours ago
Allegations That Establish Breach of a Condition Defeats Suit

Notice of Claim Later than 60 Days After Expiration is Too Late

Post 5089

Injury at Massage Causes Suit Against Therapist

Read the full article at https://lnkd.in/gziRzFV8, see the full video at https://lnkd.in/gF4aYrQ2 and at https://lnkd.in/gqShuGs9, and at https://zalma.com/blog plus more than 5050 posts.

Hiscox Insurance Company (“Hiscox”) moved the USDC to Dismiss a suit for failure to state a claim because the insured reported its claim more than 60 days after expiration of the policy.

In Mluxe Williamsburg, LLC v. Hiscox Insurance Company, Inc., et al., No. 4:25-cv-00002, United States District Court, E.D. Missouri, Eastern Division (May 22, 2025) the trial court’s judgment was affirmed.

FACTUAL BACKGROUND

Plaintiff, the operator of a massage spa franchise, entered into a commercial insurance agreement with Hiscox that provided liability insurance coverage from July 25, 2019, to July 25, 2020. On or about June 03, 2019, a customer alleged that one of Plaintiff’s employees engaged in tortious ...

00:08:31
June 02, 2025
Zalma’s Insurance Fraud Letter – June 1, 2025

ZIFL – Volume 29, Issue 11
The Source for the Insurance Fraud Professional
Posted on June 2, 2025 by Barry Zalma

Post 5087

See the full video at and at

Read the full article and the full issue of ZIFL June 1, 2025 at https://zalma.com/blog/wp-content/uploads/2025/05/ZIFL-06-01-2025.pdf

Zalma’s Insurance Fraud Letter – June 1, 2025

See the full video at https://lnkd.in/gw-Hgww9 and at https://lnkd.in/gF8QAq4d, and at https://zalma.com/blog plus more than 5050 posts.

ZIFL – Volume 29, Issue 11

The Source for the Insurance Fraud Professional

Read the full article and the full issue of ZIFL June 1, 2025 at https://lnkd.in/gTWZUnnF

Zalma’s Insurance Fraud Letter (ZIFL) continues its 29th year of publication dedicated to those involved in reducing the effect of insurance fraud. ZIFL is published 24 times a year by ClaimSchool and is written by Barry Zalma. It is provided FREE to anyone who visits the site at ...

00:08:42
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May 30, 2025
Plain Language of Policy Enforced

No Coverage if Home Vacant for More Than 60 Days

Failure to Respond To Counterclaim is an Admission of All Allegations

Post 5085

See the full video at https://lnkd.in/gbWPjHub and at https://lnkd.in/gZ9ztA-P, and at https://zalma.com/blog plus more than 5050 posts.

In Nationwide Mutual Insurance Company v. Rebecca Massey, Civil Action No. 2:25-cv-00124, United States District Court, S.D. West Virginia, Charleston Division (May 22, 2025) Defendant Nationwide Mutual Insurance Company's (“Nationwide”) motion for Default Judgment against Plaintiff Rebecca Massey (“Plaintiff”) for failure to respond to a counterclaim and because the claim was excluded by the policy.

BACKGROUND

On February 26, 2022, Plaintiff's home was destroyed by a fire. At the time of this accident, Plaintiff had a home insurance policy with Nationwide. Plaintiff reported the fire loss to Nationwide, which refused to pay for the damages under the policy because the home had been vacant for more than 60 days.

Plaintiff filed suit ...

00:06:50
May 15, 2025
Zalma's Insurance Fraud Letter - May 15, 2025

ZIFL Volume 29, Issue 10
The Source for the Insurance Fraud Professional

See the full video at https://lnkd.in/gK_P4-BK and at https://lnkd.in/g2Q7BHBu, and at https://zalma.com/blog and at https://lnkd.in/gjyMWHff.

Zalma’s Insurance Fraud Letter (ZIFL) continues its 29th year of publication dedicated to those involved in reducing the effect of insurance fraud. ZIFL is published 24 times a year by ClaimSchool and is written by Barry Zalma. It is provided FREE to anyone who visits the site at http://zalma.com/zalmas-insurance-fraud-letter-2/ You can read the full issue of the May 15, 2025 issue at http://zalma.com/blog/wp-content/uploads/2025/05/ZIFL-05-15-2025.pdf
This issue contains the following articles about insurance fraud:

Health Care Fraud Trial Results in Murder for Hire of Witness

To Avoid Conviction for Insurance Fraud Defendants Murder Witness

In United States of America v. Louis Age, Jr.; Stanton Guillory; Louis Age, III; Ronald Wilson, Jr., No. 22-30656, United States Court of Appeals, Fifth Circuit (April 25, 2025) the Fifth Circuit dealt with the ...

May 15, 2025
CGL Is Not a Medical Malpractice Policy

Professional Health Care Services Exclusion Effective

Post 5073

See the full video at https://lnkd.in/g-f6Tjm5 and at https://lnkd.in/gx3agRzi, and at https://zalma.com/blog plus more than 5050 posts.

This opinion is the recommendation of a Magistrate Judge to the District Court Judge and involves Travelers Casualty Insurance Company and its duty to defend the New Mexico Bone and Joint Institute (NMBJI) and its physicians in a medical negligence lawsuit brought by Tervon Dorsey.

In Travelers Casualty Insurance Company Of America v. New Mexico Bone And Joint Institute, P.C.; American Foundation Of Lower Extremity Surgery And Research, Inc., a New Mexico Corporation; Riley Rampton, DPM; Loren K. Spencer, DPM; Tervon Dorsey, individually; Kimberly Dorsey, individually; and Kate Ferlic as Guardian Ad Litem for K.D. and J.D., minors, No. 2:24-cv-0027 MV/DLM, United States District Court, D. New Mexico (May 8, 2025) the Magistrate Judge Recommended:

Insurance Coverage Dispute:

Travelers issued a Commercial General Liability ...

April 30, 2025
The Devil’s in The Details

A Heads I Win, Tails You Lose Story
Post 5062

Posted on April 30, 2025 by Barry Zalma

"This is a Fictionalized True Crime Story of Insurance Fraud that explains why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The story is designed to help everyone to Understand How Insurance Fraud in America is Costing Everyone who Buys Insurance Thousands of Dollars Every year and Why Insurance Fraud is Safer and More Profitable for the ­­­Perpetrators than any Other Crime."

Immigrant Criminals Attempt to Profit From Insurance Fraud

People who commit insurance fraud as a profession do so because it is easy. It requires no capital investment. The risk is low and the profits are high. The ease with which large amounts of money can be made from insurance fraud removes whatever moral hesitation might stop the perpetrator from committing the crime.

The temptation to do everything outside the law was the downfall of the brothers Karamazov. The brothers had escaped prison in the old Soviet Union by immigrating to the United...

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