ZIFL Volume 28 No. 22
Post 4939
Read the full article at Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdfand at https://zalma.com/blog.
The Source for the Insurance Fraud Professional https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf
Zalma’s Insurance Fraud Letter (ZIFL) continues its 28th 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/ This issue contains the following articles about insurance fraud:
The EUO is a Material Condition Precedent
A Key Tool in the Effort to Reduce Fraud
Claim Properly Denied for Refusal to Testify at EUO
I spoke recently at the Conference of the Southern California Fraud Investigators Association on the Examination Under Oath as a tool to help insureds prove their losses and what happens when an insured fails or refuses to testify. This case emphasizes the purpose of my talk.
Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf
Thanksgiving Wishes from the Zalma Family
My family and I have much to be thankful for this year. My first born daughter, Stephanie Zalma, continues to care for my wife 24 hours a day 7 days a week with love and patience as Thea continues as Nana to our two grandchildren and the loving mother of our three children.
After receiving a new Aortic Heart Valve I am personally in good health, walking about 25 miles a week. Exercising my, apparently unusual mode of retirement, I work only six to eight hours a day doing what I love the most, writing about insurance, insurance claims, insurance law and acting as an insurance claims consultant and expert witness.
Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf
More McClenny Moseley & Associates Issues
This is ZIFL’s thirty eighth 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 may be criminal to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana.
Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf
Ethical Behavior & Insurance
Insurance, from the time of its first agreement to the present day has always been a business requiring ethical behavior between the insurer and the insured and between the insured and the insurer.
The concept of ethical behavior refers to well-founded standards of right and wrong that prescribe what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues, all of which are essential to the lawyer.
Ethics refers to those standards that impose the reasonable obligations to refrain from murder, rape, theft, assault, slander, and fraud. Ethical standards also include those that imply virtues of honesty, compassion, and loyalty.
There are rights presumed to exist such as those described in the Declaration of Independence submitted to King George of England in 1776 that held:
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of happiness.
The unalienable rights also include the right to life, the right to freedom from injury, and the right to liberty. Such standards are adequate standards of ethics because they are supported by consistent and well-founded reasons.
Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf
Health Insurance Fraud Convictions
Michigan Woman Convicted of $1.4M Health Care Kickback Scheme
Mary Smettler-Bolton, 71, of Oakland County, Michigan was convicted November 22, 2024 for her role in a conspiracy to defraud the United States and receive illegal health care kickbacks.
According to court documents and evidence presented at trial, Mary referred Medicare beneficiaries to several Metro Detroit home health companies in exchange for hundreds of thousands of dollars in kickbacks paid by the owners and operators of the home health companies. Over the course of four years, she and her co-conspirators caused over $1.4 million of loss to Medicare.
Smettler-Bolton was convicted of one count of conspiracy to defraud the United States and receive illegal health care kickbacks and one count of violating the federal Anti-Kickback Statute. She is scheduled to be sentenced on March 3, 2025, and faces a maximum penalty of five years in prison on the conspiracy count and a maximum penalty of 10 years in prison on the kickback 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 about dozens more convictions at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf
Convictions of Other Than Health Insurance Fraud
Creative Fraudster Guilty of $229K Insurance Fraud Schemes
Justin Mack, a native of Buffalo, New York, and a resident of Cleveland, Ohio, was sentenced on November 25, 2024 in the Cuyahoga County Court of Common Pleas. Mack, an Ohio man was sentenced to five years in prison and ordered to pay restitution for filing 24 fraudulent claims with multiple insurance companies, totaling more than $229,000.
An extensive investigation uncovered Mack’s pattern of submitting altered documentation, falsified claims, and using other people’s identities to fraudulently secure payouts from multiple insurance companies.
Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf
The Examination Under Oath Is Not Part of a Judicial Process
Although the EUO is a formal proceeding it is not part of a judicial process nor is it subject to the rules set out by codes of civil procedure. There is no right to object to questions and never a judge present to rule on the objections. The testimony at the EUO is required to be presented in accordance with the obligation imposed on an insured to deal fairly and in good faith with the insurer.
Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf
Barry Zalma
Barry Zalma, Inc., 4441 Sepulveda Boulevard, CULVER CITY CA 90230-4847, 310-390-4455. Subscribe to Excellence in Claims Handling at https://barryzalma.substack.com/welcome. Write to Mr. Zalma at [email protected]; https://www.zalma.com; https://zalma.com/blog. He publishes daily articles at https://zalma.substack.com, 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/; Go to X @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/ and GTTR at https://gettr.com/@zalma
Anti-Public Adjuster Clause Is Effective in New York
Post number 5301
Read the full article at https://www.linkedin.com/pulse/public-adjusters-attempt-represent-insured-subject-zalma-esq-cfe-rubfc, see the video at and at and at https://zalma.com/blog plus more than 5300 posts.
Insurers May Contractually Prevent an Insured from Hiring a Public Adjuster
In Peter Barbato & North Jersey Public Adjusters Inc. v. Interstate Fire & Casualty Company, et al, No. 25-cv-5312 (JGK), United States District Court, S.D. New York (December 15, 2025) the plaintiffs, Peter Barbato and North Jersey Public Adjusters, Inc. (“NJPA”), filed suit against several insurance companies, including Interstate Fire & Casualty Company, Independent Specialty Insurance Company, and certain Underwriters at Lloyd’s of London.
FACTS
NJPA is a New Jersey-based public adjusting firm licensed in New York. The dispute centers on ...
Anti-Public Adjuster Clause Is Effective in New York
Post number 5301
Read the full article at https://www.linkedin.com/pulse/public-adjusters-attempt-represent-insured-subject-zalma-esq-cfe-rubfc, see the video at and at and at https://zalma.com/blog plus more than 5300 posts.
Insurers May Contractually Prevent an Insured from Hiring a Public Adjuster
In Peter Barbato & North Jersey Public Adjusters Inc. v. Interstate Fire & Casualty Company, et al, No. 25-cv-5312 (JGK), United States District Court, S.D. New York (December 15, 2025) the plaintiffs, Peter Barbato and North Jersey Public Adjusters, Inc. (“NJPA”), filed suit against several insurance companies, including Interstate Fire & Casualty Company, Independent Specialty Insurance Company, and certain Underwriters at Lloyd’s of London.
FACTS
NJPA is a New Jersey-based public adjusting firm licensed in New York. The dispute centers on ...
Proof of Highly Contaminated Water is Required for Extra Payments
Post number 5300
Read the full article at https://www.linkedin.com/pulse/acting-your-own-lawyer-foolish-barry-zalma-esq-cfe-mbg0c, see the video at and at and at https://zalma.com/blog plus more than 5300 posts.
Acting as Your Own Lawyer is Foolish
Evidence of Breach of Contract Survives Dismissal of All Other Charges
In Lee Lifeng Hsu and Jane Yuchen Hsu v. State Farm Fire And Casualty Company, C. A. No. N24C-09-020 CLS, Superior Court of Delaware (February 27, 2026) a claim to State Farm who paid approximately $61,000 after assessments but denied coverage for additional items including ceramic tiles, the kitchen floor ceiling, underlayment plywood, and numerous personal property items resulted in suit by the Hsu’s acting in pro per.
Facts
Lee Lifeng Hsu and Jane Yuchen Hsu (“Plaintiffs”) purchased a homeowners’ insurance policy from State Farm Fire...
Insurance Condition Requires Following the Intent of the Parties
Post number 5307
Principles of Contract Interpretation Compels Reading Contract as Written
Read the full article at https://www.linkedin.com/pulse/portable-storage-containers-buildings-barry-zalma-esq-cfe-fkg1c and at https://zalma.com/blog.
In Eastside Floor Supplies, Ltd. v. SCS Agency, Inc., Hanover Insurance Company, et al., No. 2024-01501, Index No. 609883/19, 2026 NY Slip Op 01488, Supreme Court of New York, Second Department (March 18, 2026)
In May 2019, a fire damaged business personal property belonging to the plaintiffs, which was stored in portable storage containers at their Manhattan premises. At the time of the fire, the plaintiffs were insured under a businessowners insurance policy (BOP) issued by the defendant Hanover Insurance Company which provided general coverage for business personal property, and which included a specific extension for “Business Personal Property Temporarily in Portable Storage Units” (the portable storage ...
ERISA Saves Fraudulent Claims Suit
Post number 5306
Read the full article at https://www.linkedin.com/pulse/failure-provide-well-pled-facts-defeats-most-action-zalma-esq-cfe-b4zuc and at https://zalma.com/blog plus more than 5300 posts.
Allegations of Fraudulent Insurance Billing Must be Pleaded with Specificity
In Genesis Laboratory Management LLC v. United Healthcare Services, Inc. and Oxford Health Plans, Inc., No. 21cv12057 (EP) (JSA), United States District Court, D. New Jersey (March 13, 2026) Genesis Laboratory Management LLC (“Genesis”), a New Jersey-based molecular diagnostic and anatomic pathology laboratory, provided COVID-19 related testing services and submitted claims for reimbursement as an out-of-network provider to United Healthcare Services, Inc. (“United”) and Oxford Health Insurance, Inc. (“Oxford”). Metropolitan Healthcare Billing, LLC (“Metropolitan”), owned by the same individual as Genesis, handled the billing for Genesis.
FACTUAL BACKGROUND
United and Oxford, who administer both ERISA and ...
ERISA Saves Fraudulent Claims Suit
Post number 5306
Read the full article at https://www.linkedin.com/pulse/failure-provide-well-pled-facts-defeats-most-action-zalma-esq-cfe-b4zuc and at https://zalma.com/blog plus more than 5300 posts.
Allegations of Fraudulent Insurance Billing Must be Pleaded with Specificity
In Genesis Laboratory Management LLC v. United Healthcare Services, Inc. and Oxford Health Plans, Inc., No. 21cv12057 (EP) (JSA), United States District Court, D. New Jersey (March 13, 2026) Genesis Laboratory Management LLC (“Genesis”), a New Jersey-based molecular diagnostic and anatomic pathology laboratory, provided COVID-19 related testing services and submitted claims for reimbursement as an out-of-network provider to United Healthcare Services, Inc. (“United”) and Oxford Health Insurance, Inc. (“Oxford”). Metropolitan Healthcare Billing, LLC (“Metropolitan”), owned by the same individual as Genesis, handled the billing for Genesis.
FACTUAL BACKGROUND
United and Oxford, who administer both ERISA and ...
