ZIFL Volume 27, Issue 14 -The Source For Insurance Fraud Professionals
Barry Zalma
Jul 17, 2023
Read the full article at https://lnkd.in/gWfQa8Pn and see the full video at https://lnkd.in/gzNixtbR and at https://lnkd.in/gMPsB7d2 and at https://lnkd.in/gs2DcrxB and at https://zalma.com/blog plus more than 4550 posts.
This, the fourteenth issue of the 27th year of publication Zalma’s Insurance Fraud Letter provides multiple articles on how to deal with insurance fraud in the United States. The issue begins with:
No Coverage Under a False Name
Liars May Never Prosper
Cheryl Tisdale was injured in an automobile collision while she was driving her own vehicle containing passengers while logged into the Uber Technologies (“Uber”) application as a paid driver. Tisdale served Farmers Insurance Exchange with the complaint, seeking underinsured motorist (“UM”) coverage pursuant to an insurance policy Farmers issued to Raiser, LLC, a subsidiary of Uber.
It takes a great deal of chutzpah (unmitigated gall) to be fired by Uber for cause, rejoining Uber under a false name, and then claim a right to benefits from the Uber policy. Tisdale was punished by her lies and was not allowed to profit from her fraud.
Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf
More McClenny Moseley & Associates Issues
This is ZIFL’s tenth installment of the saga of McClenny, Moseley & Associates and its problems with the federal courts in the State of Louisiana and what appears to be an effort to profit from what some Magistrate and District judges indicate may be criminal conduct to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana.
Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf
Ethics for Independent Insurance Adjusters
Independent insurance adjusters serve insurance companies who do not have sufficient claims staff to handle insurance claims on behalf of those various insurers without staff in every jurisdiction where there is property the risk of loss of which was insured.
The professional insurance adjuster recognizes that the work of adjusting insurance claims is a profession of public trust. Independent insurance adjusters should maintain a standard of integrity that will promote the goal of building public confidence and trust in the insurance industry.
Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf
Good News From the Coalition Against Insurance Fraud
This fraudster worked with a former school principal to scam healthcare benefits; now, he’s gotten schooled by a jury for his fraud. Matthew Puccio from Randolph, New Jersey, has been convicted of scheming to defraud public health benefits plans and has been sentenced to five years in federal prison. Working as a sales representative for several pharmacies between November 2014 and March 2016, Puccio conspired with others to induce two New Jersey doctors to write phony prescriptions for compounded medications on behalf of patients Puccio recruited. Puccio received kickbacks in a scheme targeting health plans that reimbursed for compound drugs at high rates. His brother-in-law, Peter Frazzano, former principal of the Sussex Avenue Elementary School in Morris Township, awaits sentencing for his role in the scam. Frazzano pleaded guilty in 2019 to conspiring to defraud the New Jersey School Employees’ Health Benefits Program, the New Jersey State Health Benefits Plan, and other plans, out of $2.7M over the same period from 2014 to 2016.
Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf
How to Add to the Professionalism of The Insurance Claims Profession
The insurance industry has been less than effective in training its personnel. Their employees, whether in claims, underwriting or sales, are hungry for education and training to improve their work in the industry.
Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf
California Commissioner Lara Announced Over $50.5 Million In Grants Awarded Statewide to Assist Law Enforcement in Fighting Fraud
Press release from the California Department of Insurance
Under Commissioner Lara’s leadership, these grants, funded through annual employer assessments, support law enforcement efforts in investigating and prosecuting fraud and increase outreach to our communities. Commissioner Lara also awarded an additional $400,000 in grants to protect consumers, the majority of whom are seniors, from abuse involving the sale of individual life and annuity products as part of the Life and Annuity Consumer Protection Program.
Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf
Health Insurance Fraud Convictions
Diversicare and Two Occupational Therapy Assistants to Pay Over $1.3 Million
Diversicare Healthcare Services, LLC, with related subsidiary Diversicare entities (Diversicare), along with Certified Occupational Therapy Assistants Kellie S. Lemons and Charles M. James, have agreed to pay the United States $1,377,696.00 to resolve allegations that they violated the False Claims Act (FCA) by submitting claims to Medicare for occupational therapy services that they did not provide.
Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf
New California Bar Rule
California Supreme Court Approves New Rule Requiring Attorneys to Report Professional Misconduct
New California Rule Compelling Attorneys to Report Misconduct by Other Attorneys to Circulate for Public Comment
In late June, the California Supreme Court approved a new Rule of Professional Conduct, rule 8.3, that will require California lawyers to report misconduct by other California attorneys. Specifically, the rule requires reporting when an attorney “has committed a criminal act or has engaged in conduct involving dishonesty, fraud, deceit, or reckless or intentional misrepresentation or misappropriation of funds or property that raises a substantial question as to that lawyer’s honesty, trustworthiness, or fitness as a lawyer in other respects.” The rule is operative August 1, 2023.
Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf
Other Insurance Fraud Convictions
Former Santa Rosa Agent Sentenced to Prison After Stealing from Consumers
Christopher Ramos, 45, of Santa Rosa, was sentenced today to four years in prison after an investigation by the California Department of Insurance found he stole over $189,000 from consumers and left them uninsured. Ramos was convicted of multiple felony counts of grand theft, theft of fiduciary funds and additional enhancements for theft over $100,000.00.
Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf
The Effect of the Tort of Bad Faith
It is indisputable that in the 1950’s, 1960’s and 1970’s the insurance industry abused some insureds to avoid paying legitimate claims. Without a factual basis, insureds were accused of arson or other variations on insurance fraud. Indemnity payments were refused on the flimsiest of excuses. People were found to have diseases that only horses could catch. Disability payments were refused because an insured was wheeled in her wheelchair to church one day and, therefore, was not totally house-confined. Insureds were driven into bankruptcy when reasonable demands within policy limits were refused.
Read the full issue of ZIFL at ZIFL-07-15-2023 http://zalma.com/blog/wp-content/uploads/2023/07/ZIFL-07-15-2023.pdf
Barry Zalma
Over the last 55 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. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support Write to Mr. Zalma at [email protected]; http://www.zalma.com; http://zalma.com/blog; I publish daily articles at https://zalma.substack.com, 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 the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ to consider more than 50 volumes written by Barry Zalma on insurance and insurance claims handling.
Go to Zalma’s Insurance Fraud Letter at https://zalma.com/zalmas-insurance-fraud-letter-2/
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/ and GTTR at https://gettr.com/@zalma
Jury’s Findings Interpreting Insurance Contract Affirmed
Post 5105
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Madelaine Chocolate Novelties, Inc. (“Madelaine Chocolate”) appealed the district court’s judgment following a jury verdict in favor of Great Northern Insurance Company (“Great Northern”) concerning storm-surge damage caused by “Superstorm Sandy” to Madelaine Chocolate’s production facilities.
In Madelaine Chocolate Novelties, Inc., d.b.a. The Madelaine Chocolate Company v. Great Northern Insurance Company, No. 23-212, United States Court of Appeals, Second Circuit (June 20, 2025) affirmed the trial court ruling in favor of the insurer.
BACKGROUND
Great Northern refused to pay the full claim amount and paid Madelaine Chocolate only about $4 million. In disclaiming coverage, Great Northern invoked the Policy’s flood-exclusion provision, which excludes, in relevant part, “loss or damage caused by ....
Failure to Name a Party as an Additional Insured Defeats Claim
Post 5104
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Contract Interpretation is Based on the Clear and Unambiguous Language of the Policy
In Associated Industries Insurance Company, Inc. v. Sentinel Insurance Company, Ltd., No. 23-CV-10400 (MMG), United States District Court, S.D. New York (June 16, 2025) an insurance coverage dispute arising from a personal injury action in New York State Supreme Court.
The underlying action, Eduardo Molina v. Venchi 2, LLC, et al., concerned injuries allegedly resulting from a construction accident at premises owned by Central Area Equities Associates LLC (CAEA) and leased by Venchi 2 LLC with the USDC required to determine who was entitled to a defense from which insurer.
KEY POINTS
Parties Involved:
CAEA is insured by Associated Industries Insurance Company, Inc. ...
Exclusion Establishes that There is No Duty to Defend Off Site Injuries
Post 5103
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Attack by Vicious Dog Excluded
In Foremost Insurance Company, Grand Rapids, Michigan v. Michael B. Steele and Sarah Brown and Kevin Lee Price, Civil Action No. 3:24-CV-00684, United States District Court, M.D. Pennsylvania (June 16, 2025)
Foremost Insurance Company (“Foremost”) sued Michael B. Steele (“Steele”), Sarah Brown (“Brown”), and Kevin Lee Price (“Price”) (collectively, “Defendants”). Foremost sought declaratory relief in the form of a declaration that
1. it owes no insurance coverage to Steele and has no duty to defend or indemnify Steele in an underlying tort action and
2. defense counsel that Foremost has assigned to Steele in the underlying action may withdraw his appearance.
Presently before the Court are two ...
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 ...
Professional Health Care Services Exclusion Effective
Post 5073
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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 ...
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...
