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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Insurance Expert May Not Testify to Speculative and Contains Unsupported Conclusions.
Posted on September 18, 2026 by Barry Zalma
See the full video at and at https://rumble.com/v7fmifw-expert-may-only-testify-to-what-experience-supports.html
In Michele A. Over, and The Estate Of Paul R. Over v. State Farm Mutual Automobile Insurance Company, and State Farm Fire And Casualty Company, Civil Action No. 23-cv-02243-PAB-STV, United States District Court, D. Colorado (September 14, 2026) Michele and Paul Over sued State Farm Fire and State Farm Auto over hail-damage and stolen-vehicle claims.
The operative dispute concerned State Farm Auto’s motion to exclude or limit opinions from plaintiffs’ insurance-industry expert, Aaron Castillo. Castillo.
Law
The proponent of expert testimony must establish by a preponderance of the evidence that an expert is qualified and that the opinions are helpful, sufficiently grounded, and reliably derived and applied. Experience-based opinions must explain how the...
150 Months in Prison for Tax Fraud
Post 4846
Posted on September 17, 2026 by Barry Zalma
See the full video at https://lnkd.in/g8rh3JBX and https://lnkd.in/gmkdy-9C, In United States Of America v. Thomas Addaquay, Nos. 25-10609, 25-10611, United States Court of Appeals, Eleventh Circuit (September 9, 2026) the Eleventh Circuit affirmed all challenged convictions, the 150-month aggregate sentence, and the challenged $4,123,474.55 restitution award.
FACTS
In United States Of America v. Thomas Addaquay, United States Of America v. Thomas Addaquay, Nos. 25-10609, 25-10611, United States Court of Appeals, Eleventh Circuit (September 9, 2026) the Eleventh Circuit affirmed all challenged convictions, the 150-month aggregate sentence, and the challenged $4,123,474.55 restitution award.
FACTS
Thomas Addaquay controlled United Consolidated Accounting and Business Services (UC), nominally a check-cashing business.
The government proved a three-stage tax-refund scheme that converted the resulting refund checks into usable funds through ...
Major Fraud Perpetrator Asserts Fifth Amendment Privilege to Avoid Prosecution
Post 5489
Posted on September 14, 2026 by Barry Zalma
Fraudster Refuses to Answer Questions About His Alleged Fraud
See the full video at https://lnkd.in/gvicAMDr and at https://lnkd.in/gvicAMDr
In Great American Insurance Co. v. Gemstone Property Management, LLC, et al., No. 23-cv-9100 (LJL), United States District Court, S.D. New York (September 8, 2026) Great American Insurance Company alleged that it was defrauded through a scheme in which Subin Associates, LLP recruited individuals to stage construction-site injuries, arranged unnecessary medical treatment and litigation funding, and pursued fraudulent personal-injury claims.
Luis Manuel Garcia Salcedo, resulted in a $6 million settlement. Non-party Jose Hernandez allegedly worked as an assistant manager at Subin, operated Hernandez Associates, and owned litigation-funding companies that shared office space with Subin and provided services to its clients.
After Great American ...
Claims of Res Judicata and Procedural Default Defeats Habeas
Post 5543
Posted on November 13, 2026 by Barry Zalma
A Health Insurance Fraud Conviction Rested On Knowingly Submitting Materially False Or Misleading Claim Information With Specific Intent To Defraud.
A Health Insurance Fraud Conviction Rested On Knowingly Submitting Materially False Or Misleading Claim Information With Specific Intent To Defraud.
In Tariq Mustafa Abdulaziz v. Commissioner Of Correction, No. CV 26-5002432-S, Superior Court of Connecticut, Judicial District of Tolland, Habeas Docket (October 29, 2026) Tariq Mustafa Abdulaziz submitted 114 claims for in-home, face-to-face services purportedly provided to thirty program participants during four one-week periods. The department paid Neurostrategies, Inc., $13,650.
FACTS
The defendant waived his right to a jury trial and elected a trial to the court, D'Addabbo, J. Trial occurred over the course of eight days in August, 2022. The state presented testimony from ten witnesses and introduced thirty-three exhibits into ...
Theft of Confidential Information
Post 4581
Posted on November 12, 2026 by Barry Zalma
In People Center, Inc. v. Deel, Inc., et al., No. 25-cv-02576-CRB (LJC), United States District Court, N.D. California (November 7, 2026) People Center, doing business as Rippling, and Deel compete in payroll and human-resource management software. Rippling alleges that Deel and its executives recruited Rippling employee Keith O’Brien, based in Ireland, to disclose confidential information and trade secrets.
THE IRISH SUIT
Rippling sued O’Brien in Ireland and Deel in the United States. O’Brien subsequently retained separate counsel, supplied an affidavit describing the alleged espionage, and entered into a Cooperation Agreement with Rippling. In exchange for his cooperation, Rippling agreed to provide financial assistance, indemnification, and conditional dismissal of the Irish proceedings. The agreement also permitted renewed proceedings or a monetary judgment upon a material breach.
The Irish proceedings against O’Brien were dismissed...
A Proposed Amended Complaint That Includes New Factual Allegations to Remedy Pleading Deficiencies
Posted on November 11, 2026 by Barry Zalma
After Dismissal Fraud Victim May Amend Complaint After Dismissal
Post 4580
If A Proposed Amendment Is Not Clearly Futile, Then Denial Of Leave To Amend Is Improper
In John Hancock Life & Health Insurance Company v. Caring Connections LLC, Arthur Feldheim, and Blime a/k/a Vera Feldheim, Civ. No. 25-7574 (MAS)(JBD), United States District Court, D. New Jersey (November 6, 2026) John Hancock sued Caring Connections LLC, Arthur Feldheim, and Blime a/k/a Vera Feldheim on June 5, 2025, asserting thirteen claims, including fraud, breach of contract, and aiding and abetting fraud.
On March 26, 2026, this Court entered an order granting Caring Connections’ motion to dismiss and granting in part and denying in part the Feldheims’ motion to dismiss. The dismissed claims were dismissed without prejudice, and John Hancock timely sought leave to amend.
They also argued that the New ...
