Investigating a Fraud Claim
Read the full article at https://www.linkedin.com/pulse/fraud-presentation-claim-barry-zalma-esq-cfe-44sec, see the full video at https://rumble.com/v64ap97-fraud-in-the-presentation-of-a-claim.html and at https://youtu.be/qV2_b5DOhEc, and at https://zalma.com/blog plus more than 4900 posts.
Post 4959
To properly investigate a fraudulent insurance claim it is necessary that the investigator and the insurer for whom he works, understands the law relating to insurance fraud and the rights the insurer, and its investigators have, to obtain the necessary evidence to prove a fraud has been attempted.
INSURANCE FRAUD
Insurance fraud in the presentation of a claim, by definition, voids insurance. In 1884 the U.S. Supreme Court considered the issue and decided that a fraud in the presentation of a claim, even if it was not intended to deceive the insurer and would have had little effect on the indemnity paid, still caused the policy to be void and the claim to be denied.
In Claflin & Others v. Commonwealth Insurance Company.; Same v. Western Assurance Company.; Same v. Franklin Insurance Company, 110 U.S. 81; 3 S. Ct. 507; 28 L. Ed. 76; 1884 U.S. LEXIS 1661 the U.S. Supreme Court found that after a loss, a person named Murphy assigned his claims against the several companies under the policies to the plaintiffs.
Claflin holds that the materiality of a statement is not defined and determined by the effect it has on the outcome of the investigation. Rather, a question and answer are material when they relate to the insured’s duty to give to the insurer all the information he has as well as other sources of information so that the insurer can make a determination of its obligations.
Defendant insurers had issued insurance policies on certain goods. Plaintiffs were assigned the goods and brought suits under the policies against defendants as assignees of the original insured. After determining that the lower court had jurisdiction over the matter, the court affirmed judgment for defendants because the record showed the assignor had made false statements and therefore plaintiff assignees could not prevail.
In any view, there was a fraud attempted upon the insurers; and it is not lessened because the motive that induced it was something in addition to the possible injury to them that it might work. The supposition proceeds upon the very ground of the false statement of a material matter, knowingly and wilfully made, with the intent to deceive the defendants in error; and it is no palliation of the fraud that Murphy did not mean thereby to prejudice them, but merely to promote his own personal interest in a matter not involved in the contract with them. By that contract the companies were entitled to know from him all the circumstances of his purchase of the property insured, including the amount of the price paid and in what manner payment was made; and false statements, wilfully made under oath, intended to conceal the truth on these points, constituted an attempted fraud by false swearing which was a breach of the conditions of the policy, and constituted a bar to the recovery of the insurance.
INTENTIONAL MISREPRESENTATION
Almost every insurance policy issued in the United States has a clause equal to or similar to that in the New York Standard Fire Insurance policy, that like the standard fire policy in most states, provides, that provides in relevant part, as follows: “This entire policy shall be void if, whether before or after a loss, the insured has willfully concealed or misrepresented any material fact or circumstance concerning this insurance or the subject thereof, or the interest of the insured therein, or in case of any fraud or false swearing by the insured relating thereto.”
The fraud investigator must understand that an insured who lies about material facts is grounds to refuse coverage for fraud. For example, when an insured lied intentionally about a claim to prevent her criminally violent son from harming her physically sued the insurer who denied the claim when it learned she had lied to them. She failed to recover any benefits because the concealment or fraud provision of her policy effectively barred her claim.
ZALMA OPINION
Anyone who is charged with investigating insurance fraud must gather admissible evidence that shows an intentional misrepresentation or concealment of material facts. With that evidence the right to the benefits of an insurance policy are forfeited.
(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
See the video at https://lnkd.in/gqh7V46x and at https://lnkd.in/gmE-zrDC and at https://zalma.com/blog plus more than 5200 posts.
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 ...
