STATUTORY OBLIGATION TO FIGHT FRAUD INCLUDES THE RIGHT TO EXAMINE PEOPLE CLAIMING NO FAULT INJURIES UNDER OATH
Apparent Staged Accident Requires EUO to Investigate Potential Fraud
Post 4995
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The trial court initially denied Allstate’s suit stating that Allstate failed to show good cause and did not cite any contractual provision compelling the Appellees to provide information in an examination under oath (“EUO”). Allstate argued that it had a duty to investigate suspected insurance fraud and that the Appellees had a contractual obligation to submit to EUOs.
In Allstate Property And Casualty Insurance Company v. Gloria E. Companioni; Isair H. Lubo-Rodriguez; and Mercedes H. Cervantes, No. 2023-CA-1012-MR, Court of Appeals of Kentucky (February 7, 2025) resolved the dispute.
The Court of Appeals of Kentucky vacated the trial court’s total denial of the petition and remanded the case for further proceedings. The appellate court found that the trial court overlooked contractual provisions allowing Allstate to conduct EUOs and binding precedent that permits inquiries into accident-related issues. The appellate court directed the trial court to reconsider whether good cause exists to allow questioning pertaining to medical treatment and solicitation, following the principles set forth in Deadwyler v. Grange Property and Casualty Insurance Company.
The appellate court’s decision emphasized the importance of allowing insurers to conduct thorough investigations, especially when there are concerns about potential fraud. The case highlights the balance between protecting claimants’ rights and ensuring that insurers can fulfill their duty to investigate claims thoroughly.
FACTS
Gloria Companioni was driving a car insured by Allstate which was in an accident with another car. Appellees Isair Lubo-Rodriguez and Mercedes Cervantes were allegedly riding in the car Companioni was driving when the accident happened. All three resided in Kentucky.
Four days after the accident, all three Appellees commenced care at Total Health Chiropractic and Rehab (“Total Health”). The next day (five days after the accident), Appellees submitted Personal Injury Protection (“PIP”) applications through counsel. Appellees requested reimbursement for medical treatment resulting from the accident and for any coverage available, including coverage for basic reparations benefits (“BRB”).
Allstate filed a suit for an EUO pursuant to Kentucky statutes.
ANALYSIS
Trial Court Erred in Finding Allstate Failed to Cite a Contractual Provision Which Required Appellees to Submit to EUOs
The trial court overlooked policy provisions relating to EUOs, but it also overlooked pertinent authority allowing inquiries into predominantly accident-related issues in EUOs. In sum, its total denial of the EUO petition cannot stand and must be vacated with the case remanded to the trial court for further proceedings.
The appellate court directed the trial court to consider its guidance in considering anew whether good cause exists to permit questioning about matters of medical treatment and/or solicitation via EUO and, if so, to establish any appropriate limits on such questioning.
The trial court’s total denial of the EUO petition was vacated and remanded for the trial court to issue a new order allowing an EUO at least regarding purely accident-related issues, to reconsider whether good cause exists to permit inquiries pertaining to medical treatment and solicitation, and to provide direction to the parties as to the permissible scope of inquiry.
ZALMA OPINION
Kentucky, like most states, requires insurers to maintain a Special Fraud Investigative Unit to help the state defeat insurance fraud and to protect every insurer doing business in the state from damages from fraud. Allstate, faced with an apparent staged accident sought to examine the parties claiming injury under oath in its effort to fully investigate a potential insurance fraud. The trial court refused but the Court of Appeals of Kentucky reversed requiring the trial court to approve the EUOs.
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Anti-Public Adjuster Clause Is Effective in New York
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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 ...
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Principles of Contract Interpretation Compels Reading Contract as Written
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Post number 5306
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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.
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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 ...
