Medicare Supplement Plan Properly Discontinued by City
Post 5108
Read the full article at https://lnkd.in/gfHSn7nx, see the full video at https://lnkd.in/g-hkvd3h and at https://lnkd.in/gcN7BP5u, and at https://zalma.com/blog plus more than 5100 posts.
New York’s Highest Court Approves Change in Medicare Plan
The City of New York decided to discontinue its Medicare supplemental plan, Senior Care, and enroll all retirees in a custom-designed Medicare Advantage Plan (MAP) managed by Aetna Life Insurance Company. Petitioners, consisting of nine retirees and one organization, initiated legal proceedings to prevent the City from eliminating their existing health insurance plans. They argued that the City had repeatedly promised to provide and pay for a Medicare supplemental plan upon retirement, and that they relied on these promises when making financial, employment, and retirement decisions.
In the Matter of Robert Bentkowski, et al. v. City of New York, et al., 2025 NY Slip Op 03690, No. 57, New York Court of Appeals (June 18, 2025) ruled in favor of the city.
The Trial Court
The Supreme Court ruled in favor of the petitioners on their promissory estoppel cause of action and their cause of action under Administrative Code of the City of New York and the Appellate Division affirmed. The City appealed.
The primary issue before the Court of Appeals was whether petitioners were entitled to judgment on their promissory estoppel cause of action. The Court of Appeals concluded that petitioners were not entitled to judgment on this cause of action, as they failed to establish the existence of a clear and unambiguous promise of Medicare supplemental insurance coverage for life.
Promissory Estoppel:
1. The Court found that the Summary Program Descriptions (SPDs) provided by the City were descriptive and for informational purposes only and did not constitute a clear and unambiguous promise of Medicare supplemental insurance coverage for life.
2. The affidavits submitted by the petitioners, including those from Lilliam Barrios-Paoli and hundreds of retirees, were based on the SPDs and did not establish a clear and unambiguous promise.
Administrative Code § 12-126 (b) (1):
The petitioners contended that the City was required to provide and pay for a Medicare supplemental plan under Administrative Code § 12-126 (b) (1). The Court rejected this contention, stating that the requirement prohibits the City from passing any portion of the cost up to the statutory cap on to its employees and retirees, but does not require the City to fund health insurance without the benefit of federal subsidies.
Conclusion:
The Court reversed the order of the Appellate Division and remitted the matter to Supreme Court for further proceedings in accordance with its opinion.
DISCUSSION
Respondents answered, arguing, among other things, that the City’s statements in the SPDs did not constitute “a clear and unambiguous forward-looking promise sufficient to support a promissory estoppel claim.” Furthermore, respondents stated that the Aetna MAP was the product of negotiation between the City, Aetna, and the Municipal Labor Committee (MLC), which represents over 100 municipal unions in the collective bargaining process. According to respondents, the Aetna MAP would allow the City to access federal subsidies, creating $500 million in savings to be allocated to a Health Benefits Stabilization Fund to provide sufficient reserves for future health benefits.
Any inference of a lifetime promise derived from the SPDs is even less plausible in light of the prefatory language employed therein and the mayoral cover letters. Because there is no clear and unambiguous promise in the SPDs, the affidavits of Barrios-Paoli and the hundreds of retirees likewise fail to establish the existence of such a promise.
The parties stipulated to the completeness of the record. On that record, petitioners failed to introduce sufficient evidence to establish that the City’s decision to shift retirees to the Aetna MAP constitutes a diminution in retiree benefits or the City’s contributions for those benefits.
The order of the Appellate Division reversed with costs, and matter remitted to Supreme Court, New York County, for further proceedings in accordance with the opinion herein.
ZALMA OPINION
Promises to provide health insurance coverage and Medicare Supplement Coverage must be clear and unambiguously to provide such services for the life of the employee or retired employee for a court to compel the city to keep the promises. The promises of coverage were not kept because they were not made to be a “forever benefit.” Shifting benefits from one program to another did not diminish the benefits promised.
(c) 2025 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 ...
Employee Report of Fraud Results in Damages Suit After Qui Tam Suit Settled
No Statutory Hearing Right Arose Because No Dental Commission Complaint License Suspension, Revocation, Or Sanction Occurred.
Post 4855
Posted on October 2, 2026 by Barry Zalma
In Abbas Mohammadi et al. v. William M. Tong et al., No. AC 47598, Court of Appeals of Connecticut (September 29, 2026) Abbas Mohammadi owned and operated Columbia Dental, P.C., which provided dental services through multiple Connecticut offices; Columbia Oral Maxillofacial Imaging, LLC served as the billing entity.
From April 2012 to February 27, 2013, Columbia Dental employed Brittany Ames Mahoney as a dental assistant. During her employment, Mahoney claimed to have discovered certain billing irregularities, including, but not limited to, false and fraudulent reimbursement claims submitted to the Department of Social Services for services rendered to Medicaid beneficiaries. Mahoney filed a complaint and an affidavit in the United States District Court for the District of...
Another Anniversary for Barry Zalma, Inc
Posted on October 1, 2026 by Barry Zalma
From October 1, 1979 – 2026
Post 4854
Read the full issue of ZIFL at https://zalma.com/blog/wp-content/uploads/2026/09/ZIFL-10-01-2026.pdf Forty seven years ago today I left the world of the employed and became an entrepreneur by opening my own law firm. The law practice was incorporated shortly thereafter as Barry Zalma, Inc.
When I opened for business on October 1, 1979, I had no clients and no certainty that I would have any in the future. I had borrowed money from the bank to carry me through the first six months and was concerned about my ability to pay the loan with my third child about to be born.
Much to my surprise and pleasure, on October 1, 1979, at 8:10 a.m., the best claims handler in the London market, Alan Warboys, called from London and provided me with my first case as an independent lawyer to represent Certain Underwriters at Lloyd’s, London. He, and the Lloyd’s Underwriters he represented, showed faith in me as a lawyer and insurance expert. Alan is now, although ...
Defendants Successfully Moved for Summary Judgment
Post 4854
Posted on September 30, 2026 by Barry Zalma
In Jeffrey Wayne Phillips v. Creative Website Studios, et al., No. 5:23-CV-568-BO-BM, United States District Court, E.D. North Carolina, Western Division (September 28, 2026) the Court needed to rule on the order and memorandum and recommendation (“M&R”) of the Magistrate.
Jeffrey Wayne Phillips had contracted with Creative Website Studios and SR Telecommunications for website and hosting services. He alleged that defendants repeatedly billed him for hosting periods he had already paid for and later took down his website. Phillips claimed the outage prevented him from bidding on U.S. government security contracts and sought roughly $300 million in consequential damages.
LAW
Under North Carolina law, fraud requires a false material representation or concealment, intent and effect of deception, resulting damage, and reasonable reliance. Obtaining property by false pretenses similarly requires an ...
