Med Pay Only Available for Reasonable & Necessary Expenses
Read the full article at https://lnkd.in/g_q4ytQY, see the full video at https://lnkd.in/ga4hJ9KA and at https://lnkd.in/gzyzZi_D and at https://zalma.com/blog plus more than 4800 posts.
Post 4826
Kimberly Sisia appealed the district court’s dismissal with prejudice of her amended complaint against State Farm, as well as the district court’s denial of her motion for conditional class certification. In short, Sisia sought reimbursement from State Farm for medical expenses allegedly incurred because of an automobile accident that occurred in 2009. She claimed that her automobile insurance policy required State Farm to pay all of her medical expenses stemming from the accident up to the policy limit.
In Kimberly K. Sisia v. State Farm Mutual Automobile Insurance Company, No. 23-14201, United States Court of Appeals, Eleventh Circuit (June 6, 2024) the Eleventh Circuit resolved the dispute.
THE POLICY
Sisia’s automobile insurance policy states that State Farm “will pay reasonable medical expenses incurred, for bodily injury caused by accident,” and that “[t]hese expenses are for necessary medical, surgical, X-ray, dental, ambulance, hospital, professional nursing and funeral services, eyeglasses, hearing aids and prosthetic devices.” It further explains that State Farm has the right to review “medical expenses and services to determine if they are reasonable and necessary for the bodily injury sustained.”
ARGUMENT
Sisia argued that this policy unequivocally required State Farm to pay all of Plaintiff’s medical expenses incurred from her automobile accident. Sisia’s argument ignored the plain text of the policy, which unambiguously stated that State Farm must pay only for expenses that are “reasonable” and “necessary.” The policy explicitly contemplated the possibility that State Farm will not pay for medical expenses that it deems unreasonable or unnecessary.
ANALYSIS
Because the language of Sisia’s insurance policy plainly does not require State Farm to reimburse all medical expenses — only those expenses that it deems “reasonable” and “necessary.” The district court did not err in concluding that Sisia’s claim for breach of contract against State Farm could not survive a motion to dismiss. Likewise, the district court did not err in dismissing her claim that State Farm breached its duty of good faith and fair dealing. Such a claim is not actionable unless the allegations of breach are specifically tied to the breach of a contract provision.
There can be no breach of an implied covenant of good faith where a party to a contract has done what the provisions of the contract expressly give him the right to do.
Finally, the district court did not err in denying Sisia’s motion for class certification when it dismissed her complaint because her underlying claims lacked merit.
ZALMA OPINION
The Eleventh Circuit, like the USDC, did what the plaintiff did not do: they read the policy. Sisia wanted payment for all her medical expenses while the policy only allowed for payment of reasonable and necessary medical expenses relating to the accident. Therefore treatment for the common cold, a hangnail, diabetes or an illness not reasonable or necessary as a result of the accident could never be covered. Sisia was unable to change an automobile MedPay policy into a health insurance policy.
(c) 2024 Barry Zalma & ClaimSchool, Inc.
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When Harm is Inherent in the Nature of the Act it is Intentional
Post 5237
See the video at and at and at https://zalma.com/blog plus more than 5200 posts.
No Coverage for Intentional Acts
Hitting a Person in the Face is an Intentional Act
In Unitrin Auto and Home Insurance Company v. Brian C. Sullivan, et al., George A. Ciminello, No. 2022-01607, Index No. 21632/14, Supreme Court of New York, Second Department (November 19, 2025) George A. Ciminello was injured when struck in the face by a cup filled with liquid, thrown from a moving vehicle operated by Brian C. Sullivan, with Robert Harford as the passenger who threw the cup. The vehicle approached Ciminello at about 30 mph, from 2 to 10 feet away, and Harford extended his arm to make contact. The cup splintered upon impact.
Sullivan and Harford later conceded liability on the intentional tort claim before a damages trial.
Insurance Policy:
Unitrin Auto and Home...
Obtaining Title to Church by Fraud Defeated
Post 5238
Read the full article at https://www.linkedin.com/pulse/unmitigated-gall-abuse-elderly-bishop-his-church-zalma-esq-cfe-xcasc, see the video at and at and at https://zalma.com/blog plus more than 5200 posts.
It is Villainous to Steal Church Property from Sick and Elderly Bishop
In Testimonial Cathedral Local Church of God in Christ v. EquityKey Real Estate Option, LLC et al. (Cal. Ct. App., 2d Dist., Div. 8, No. B331522 (Nov. 18, 2025) EquityKey (through broker Steven Sharpe and Frank Wheaton, a trusted advisor/friend of elderly Bishop Jimmy Hackworth) presented a deal supposedly for a $4 million life-insurance policy on Hackworth’s life with EquityKey as beneficiary. In exchange, EquityKey paid Hackworth $400,000 upfront.
Factual Background
To qualify Hackworth for the large policy, church real property on South Western Ave., Los Angeles was temporarily ...
Guilty of Money Laundering Scheme
Post 5238
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Prison Sentence for Fraud Must be Limited to the Fraud in Which the Defendant Participated
In United States v. Stephen O. Anagor, No. 2:24-CR-00019-DCLC-CRW (E.D. Tenn., Nov. 26, 2025) by Judge Clifton L. Corker the government sought to increase the defendant’s sentence because his co-conspirators added a fraudulent FBI scam that resulted in the victim’s suicide. Anagor sought a lower sentence because he was only involved in part of the fraud.
Charges & Plea
Defendant, a U.S. Army soldier pled guilty on June 11, 2025 to Conspiracy to Commit Mail and Wire Fraud, Aiding and Abetting Aggravated Stalking Resulting in Death and Aiding and Abetting Aggravated Identity Theft that was part of a larger 38-count superseding indictment against Anagor and co-defendants Chinagorom Onwumere and Salma Abdalkareem for an international Nigerian-based ...
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 ...
