ZIFL Volume 27 Number 5
Barry Zalma
Read the full article at https://lnkd.in/gXiVeBE2 and see the full video at https://lnkd.in/gdTK4Qmu and at https://lnkd.in/gEhvKF4p, and read the full 22 page ZIFL in pdf format at https://lnkd.in/gzErgazV and at https://zalma.com/blog plus more than 4450 posts.
McClenny Moseley & Associates & Insurance Fraud
The McClenny Moseley & Associates (MMA) series of lawsuits, court hearings and insurance department actions have brought about some very serious problems for MMA, including court orders, lawsuit dismissals, administrative cease and desist orders and litigation, all of which have created a poster child for Zalma’s Insurance Fraud Letter.
Since MMA has admitted that it reported a claim to various insurers, including Allied Insurance, that it was presenting claims against Allied and at least 856 claims to Allied and other insurers, that it represented the insured when, in truth and fact, it did not represent the insurer’s insureds, but, rather Apex Roofing who is not an insured of any of the insurers to whom MMA made claims, demanded appraisal and settled claims, cashed checks and took attorneys fees from people it did not represent the insurer is obligated to report each claim to the Louisiana Department of Insurance as a suspected insurance fraud effected or attempted.
Therefore, it appears, subject to the review of the Louisiana Attorney General and/or local prosecutors, MMA violated Louisiana fraud statutes, and each insurer who is a victim of one or more of the minimum of 856 fraudulent claims where MMA represented it was the attorney of the insurers’ insureds was a criminal fraudulent act.
Since the actions of Velawcity and Apex Roofing appear to meet the definition of a “runner” the prosecutors in the state of Louisiana should consider prosecution for their fraudulent activities.
In addition, the federal judges involved in these cases should consider reporting MMA, Velawcity and Apex Roofing to the U.S. Attorney for investigation of the potential crime of wire fraud.
There will be more hearings in March 2023 that will be reported in the March 15, 2023 issue of ZIFL.
Read the full article and the full ZIFL at http://zalma.com/blog/wp-content/uploads/2023/02/ZIFL-03-01-2023.pdf.
The Arson for Profit Defense
To prove the “arson for profit defense” the insurer must prove the three elements needed to establish arson plus proof that the insured violated the misrepresentation, concealment, or fraud condition, and/or that the act was an intentional act to defraud the insurer.
A successful “arson for profit defense” depends on a wide range of evidence, including expert testimony, knowledgeable and convincing witnesses, and effective counsel for the insurer. Where any of the evidence as to each element is non-existent, weak, or sufficiently rebutted by the insured’s experts and witnesses, the insurer’s “arson for profit defense” will likely fail.
Read the full article and the full ZIFL at http://zalma.com/blog/wp-content/uploads/2023/02/ZIFL-03-01-2023.pdf.
Good News from the Coalition Against Insurance Fraud
A firm that administered health care claims stole $18M of funds intended for paying the claims. Anthony Riccardi started by administering third-party healthcare claims for a car dealership chain in New Canaan, Conn. Employee Benefit Solutions created invoices for the car dealership brand, which submitted payments and expected the funds to be paid to health care providers. EBS stole almost $18M of $26M the dealership paid. Most of this money was transferred into the EBS operating account and used for non-company expenses — mortgages, boats, golf and luxury cars. Riccardi only paid claims from health care providers he thought were likely to complain, or involved the car dealership execs. The scam also included inflated or bogus medical claims, including some by a phony company under Riccardi’s name. Unpaid financial obligations began to mount, prompting Riccardi to apply for millions in fraudulent bank loans and cash advances. They were used in part to pay financial obligations to the car dealership brand. To cover up the loan scheme, Riccardi forged invoices from a fake company that supposedly sold upgraded billing software to EBS. Ricardi pled federally guilty. He faces up to 30 years in prison when sentenced and agreed to repay $14.8M.
Read the full article plus many more reports of convictions and the full ZIFL at http://zalma.com/blog/wp-content/uploads/2023/02/ZIFL-03-01-2023.pdf.
How to Add to the Professionalism of Insurance Claims Professionals
Every insurer, insurance syndicate, insurance brokerage, insurance sales agency, insurer branch office, and vendors to the insurance industry should add to the libraries of their various offices or employees.
Read the full article and the full ZIFL at http://zalma.com/blog/wp-content/uploads/2023/02/ZIFL-03-01-2023.pdf.
Health Insurance Fraud Convictions
Ronald A. Beasley II, 33, of Portsmouth, Florida was the pharmacist in charge at NH Pharma, a pharmacy located in Lake Mary, Florida. Through NH Pharma, Beasley and his co-conspirators billed Medicare for expensive compound drug creams that they never
actually purchased or dispensed, and instead provided Medicare patients an inexpensive compound drug cream not covered by Medicare.
Inventory records showed that NH Pharma did not buy enough of the expensive prescription drugs to fill all the prescriptions NH Pharma billed to Medicare. In total, Beasley and his co-conspirators received more than $1 million in fraudulent proceeds from Medicare.
A federal jury in the Middle District of Florida convicted Beasley, a Virginia man February 9, 2023 for his role in a scheme to defraud Medicare of over $1 million in prescription drug benefits.
Beasley was convicted of conspiracy to commit health care fraud and three counts of health care fraud. He is scheduled to be sentenced on April 25 and faces a maximum penalty of 10 years in prison on each count. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.
Read the full article including more than a dozen convictions and the full ZIFL at http://zalma.com/blog/wp-content/uploads/2023/02/ZIFL-03-01-2023.pdf.
The Brothers Ben-Cohain
The story that follows is a fictionalized True Crime Story of Insurance Fraud from my 55 Years in Insurance that explains why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. This is one of more than 80 stories in my book “Insurance Fraud Costs Everyone“ Available as a Kindle Book and Available as a Paperback from Amazon.com.
In 1990 Moshe Ben-Cohain and Menashe Ben-Cohain started a course of conduct that led to their arrest for insurance fraud. They failed to appear after posting bond and are, along with their co-conspirator, Raz Rosenberg, fugitives.
Read the full article and the full ZIFL at http://zalma.com/blog/wp-content/uploads/2023/02/ZIFL-03-01-2023.pdf.
Other Insurance Fraud Convictions
Herbert Allen, age 38, and Dion Ridley, age 23, pleaded guilty to Conspiracy to Commit Mail Fraud in violation of Title 18, United States Code, Section 371 Allen was to 37 months in prison, followed by 3 years of supervised release and Ridley was sentenced to 6 months in prison, followed by 1 year of supervised release.
The defendants admitted to being in a conspiracy to commit mail fraud in connection with a staged automobile collision. In the scheme, Allen falsely claimed that he was the driver of a car that was struck by a tractor-trailer on June 28, 2017. Ridley, a passenger in the car, falsely claimed that Allen was driving the car and they were struck by a tractor-trailer.
In fact, the government’s evidence showed that the defendants conspired with Damien Labeaud, Roderick Hickman, and others to intentionally collide Allen’s 2007 Chevrolet Impala with a tractor-trailer in the area of Tchoupitoulas Street and Calliope Street in New Orleans.
Read the full article and about many more insurance fraud convictions and the full ZIFL at http://zalma.com/blog/wp-content/uploads/2023/02/ZIFL-03-01-2023.pdf.
(c) 2023 Barry Zalma & ClaimSchool, Inc.
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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]
Write to Mr. Zalma at [email protected]; http://www.zalma.com; http://zalma.com/blog; daily articles are published 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
Subscribe and receive videos limited to subscribers of Excellence in Claims Handling at locals.com https://lnkd.in/gfFKUaTf.
Go to substack at https://lnkd.in/gEEnV7Dd Consider subscribing to my publications at substack at https://lnkd.in/gEEnV7Dd
Barry Zalma, Esq., CFE, is available at http://www.zalma.com and [email protected]
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://lnkd.in/gWVSBde
Post Conviction Review Results in Affirmation of Sentence
Post 5036
See the full video at https://rumble.com/v6rjqp3-challenge-to-guilty-plea-fails.html and at https://youtu.be/1atskrw8-og and at https://zalma.com/blog plus more than 5000 posts.
Lewis R. Brown, appealed from the December 20, 2023 order entered in the Delaware County, Pennsylvania Court of Common Pleas denying his petition filed pursuant to the Post Conviction Relief Act (“PCRA”), 42 Pa.C.S. §§ 9541-46, as meritless.
In Commonwealth Of Pennsylvania v. Lewis R. Brown, No. 197 EDA 2024, No. J-S02022-25, Superior Court of Pennsylvania (March 24, 2025) reviewed his appeal after his request for post sentence motion to reconsider his sentence was denied.
FACTS
On June 21, 2022, Appellant entered an open guilty plea to Insurance Fraud, Theft by Deception, Criminal Use of a Communication Facility, and Conspiracy to Commit Insurance Fraud. In pleading guilty, Appellant admitted that he called his insurance company regarding a fraudulent claim from Delaware County ...
ZIFL Volume 29, Issue 7
The Source for the Insurance Fraud Professional
See the full video at https://lnkd.in/gQM9yR3n and at https://lnkd.in/gZDkH7RU, and at https://zalma.com/blog plus more than 5000 posts.
April 1, 2025
Post 5035
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 April 1, 2025 issue at https://zalma.com/blog/wp-content/uploads/2025/03/ZIFL-04-01-2025.pdf.
This issue contains the following articles about insurance fraud:
Lawyers Sanctioned for Tricking a Witness With a False Document
The United States District Court Eastern District Of Texas Marshall Division, Civil Action No. 2:23-CV-00160-JRG in a case entitled Cognipower, LLC v. Samsung Electronics Co., Ltd et al, a report was filed by David Folsom, Special ...
An Important Alternative Dispute Resolution Procedure
Post 5034
Sanctions & The Appraisal Process
Read the full article at https://lnkd.in/gTDubMra, see the full video at https://lnkd.in/gRG_iPVc and at https://lnkd.in/gJ2D7w_2 and at https://zalma.com/blog plus more than 5000 posts.
Appraisal is a form of alternative dispute resolution that sets a disputed loss amount. When an insurance policy has an appraisal provision, the right to appraisal is not permissive but is instead mandatory, so once a demand for appraisal is made, neither party has the right to deny that demand. [McGowan v. First Acceptance Ins. Co., Inc., 411 F.Supp.3d 1293, 1296 (M.D. Fla. 2019).]
Sometimes the appraisal process is abused by people attempting to abuse an insurer and bring about a future bad faith suit rather than resolve the claim. In an example of such abuse attorney Eric Dick demanded appraisal on behalf of his client only to do everything necessary to make it impossible to reach a fair award.
The Court made the following findings in ...
Read the full article at https://www.linkedin.com/pulse/duties-liabilities-insurance-brokers-barry-zalma-esq-cfe-mmpbc, if you Subscribe to “Excellence in Claims Handling” at https://barryzalma.substack.com/subscribe for only $5 a month or $50 a year.
Duties and Liabilities of Insurance Brokers
Posted on March 12, 2025 by Barry Zalma
Excellence in Claims Handling
This blog post is just a taste of the full article that is only available to subscribers to Excellence in Claims Handling. Anyone can subscribe to “Excellence in Claims Handling” at https://barryzalma.substack.com/subscribe for only $5 a month or $50 a year.
Cases in which insurance brokers’ liability is in question depend in part on whether brokers are seen to be serving a fiduciary role or simply acting as a conduit between the insured and the insurer.
A person or an entity is a fiduciary with respect to a plan to the extent:
he exercises any discretionary authority or discretionary control respecting management of such plan ...
Read the full article at https://www.linkedin.com/pulse/duties-liabilities-insurance-brokers-barry-zalma-esq-cfe-mmpbc, if you Subscribe to “Excellence in Claims Handling” at https://barryzalma.substack.com/subscribe for only $5 a month or $50 a year.
Duties and Liabilities of Insurance Brokers
Posted on March 12, 2025 by Barry Zalma
Excellence in Claims Handling
This blog post is just a taste of the full article that is only available to subscribers to Excellence in Claims Handling. Anyone can subscribe to “Excellence in Claims Handling” at https://barryzalma.substack.com/subscribe for only $5 a month or $50 a year.
Cases in which insurance brokers’ liability is in question depend in part on whether brokers are seen to be serving a fiduciary role or simply acting as a conduit between the insured and the insurer.
A person or an entity is a fiduciary with respect to a plan to the extent:
he exercises any discretionary authority or discretionary control respecting management of such plan ...
The Basics Needed by a Liability Adjuster
Post 5003
Posted on February 25, 2025 by Barry Zalma
See the full video at and at
Adjusting liability insurance claims requires skill, patience, knowledge of insurance, basic knowledge of tort and contract law, and knowledge and experience as an investigator. The liability claims adjuster is faced with the following basic obligations:
- To understand the law of torts as applied in the state where the adjuster works.
- To understand the law of contracts as applied in the state where the adjuster works.
- To understand sufficient medical terminology to be able to evaluate claims of injury.
- To understand the costs to repair or replace damaged real or personal property.
- To understand how to read and apply the terms and conditions of a liability insurance policy.
- To understand how to thoroughly investigate all claims assigned.
- To conduct an investigation of every claim ...
