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Insurance Claims professional presents articles and videos on insurance, insurance Claims and insurance law for insurance Claims adjusters, insurance professionals and insurance lawyers who wish to improve their skills and knowledge. Presented by an internationally recognized expert and author.
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19 hours ago
Go Directly to Jail: Do not Enjoy the Fourth of July

Attempt at Insurance Fraud Fails

See the full video at https://lnkd.in/gp45YiFc and at https://lnkd.in/gEknRCgC, and at https://zalma.com/blog plus more than 5100 posts.

Post 5112

The following is a fictionalized True Crime Story from my experience of Insurance Fraud. This story explains why insurance fraud is a “Heads I Win, Tails You Lose” situation for insurers and those insured. The story is presented to help you to understand how insurance fraud in America is costing everyone who buys insurance.

Arson on Independence Day Resulted in Prison for the Arsonist

The insured had no respect for his insurance company. He expected them to pay any claim he presented. He expected no investigation. Other members of the same immigrant community had successfully committed arson fraud. It was so easy for others. He decided to burn his house down.

The insured thought he was highly intelligent. He planned his arson fire carefully. He arranged for his wife and children to spend the weekend with their cousins in Oakland. He got four one-gallon cans of gasoline from four different gas stations over a two-week period. He stored the gasoline in his garage. He told his wife and children that he would join them Sunday because he had work to do Saturday in his business. After driving the wife and children to their cousins’ home in Oakland, he returned to his home in San Francisco Friday night.

Early Saturday morning July 3, the day before Independence Day, he began the preparations for the fire. He removed all of the valuable contents of the house and stored them in a rented storage facility. He packed up all of his good clothing in a suitcase and put them in the trunk of his automobile. He checked the neighborhood and found a house for rent in his general neighborhood similar to the house he lived in. He made arrangements with the owner and signed a month-to-month lease on the house. He did not notice that the owner recorded the date and time the lease was signed.

The insured spoke on the telephone with three of his customers. He visited one to show that he had, in fact, worked in his business of selling imported bathing suits that day. He then waited for the sun to set.

After it was completely dark, the insured removed one of the gasoline cans from the garage and spread the gasoline carefully throughout his living room and dining room. He returned to the garage, deposited the empty can in its hiding place, and removed two more cans. He spread them in two bedrooms and the kitchen. He made certain, while he was spreading the gasoline that the windows and doors of the house remained open to keep enough oxygen for the fire to spread. He did not turn on any lights for fear of a spark. He had turned off the pilot light on all the gas appliances. He spread the last can of gasoline around the front entry, the den, and the two bathrooms as the Fireworks shows began with bright explosions over the San Francisco Bay.

The insured did not notice that as he poured the gasoline, small droplets splashed on his shirt.

He made a final walk through the house to satisfy himself that he had spread the gasoline everywhere. There was nothing of value remaining in the house. He stood at his rear entrance and rolled up a newspaper. He lit the newspaper with his cigarette lighter and threw it into the kitchen. The gasoline had been in the kitchen for a considerable time and the fumes ignited almost instantaneously throughout the house. The flash of flames brushed the insured and ignited his gasoline-splashed shirt. He ran from the scene ripping his shirt off his body. He suffered only minor burns to his chest and back. Half naked, he ran down the street in the dark to a nearby BART station where he caught a train to Oakland. He spent the evening with his family.

The next morning, he called the San Francisco Fire Department. He told the investigator that he had chased the arsonist out of his house all the way to Montgomery Street, only to lose him at a BART station. He explained that because he was exhausted, burned and half naked, he decided to go to his cousin’s home and spend a quiet night before calling the fire department.

The insured reported the fire to his insurer the next day. He reported that the fire gutted his house. He told them he had placed his family in a rental house. He demanded an advance payment to cover the expense of the rental house.

The insured had moved his family into the rental dwelling, knowing that his policy provided coverage for additional living expenses. It was at the new rental dwelling that he first met with the adjuster.

The insured told the adjuster:

"I came home after a late dinner to find my front door open. I believed that a burglary had occurred. I was not afraid since I had served in the Soviet army in Afghanistan before coming to the United States. I walked quietly into my dark house. I could see that my television set and stereos were missing and heard someone in one of the back bedrooms. I approached the bedroom as quietly as possible. As I was about to see the burglar, they splashed me with something that smelled like gasoline. A dark figure ran past me and I chased him down the hallway. As he was leaving out my back door, he threw a match and the kitchen burst into flames. My shirt caught fire where he had splashed me and I ripped it off. Half-naked I kept running after him down the street and into the city. I chased him for at least ten blocks but he outran me. I never got a good look at him. He was about 6’2” tall, thin and I think black. My chest was burned, I was half naked and I knew my house was in flames. There was nothing I could do. I saw a BART station nearby and I bought a token and took the train to my cousin’s home in Oakland. My cousin’s house is only two blocks from the station. I spent the night with my family there.

"When I returned to San Francisco, we found the house destroyed. I rented this house so my family would have a place to sleep."

The adjuster empathized with the insured. He made clear to the insured that the policy covered additional living expenses and advances would be made as soon as possible. The adjuster promised to start his investigation immediately. He asked for documents to support the claim for additional living expenses, including the lease agreement signed by the insured.

The San Francisco Arson Unit investigated the fire. It found the fire to be clearly an arson fire. The arson unit assumed the fire was set to cover a burglary. They believed the insured’s story about confronting and chasing the robber. There was no question that the insured was burned as a result of the fire.

The insured claimed, among other things, that he had lost in the fire over 400 bathing suits and 600 pairs of pajamas. He informed the adjuster that the bathing suits and pajamas had been part of the inventory of a business that he had closed down months before and that they were no longer for sale. He said they were used by his family and friends. He had already researched the chance that the insurer would refuse coverage for these items if they were business personal property. He made it clear to the adjuster that they were not business property.

The adjuster was suspicious of this claim. He initially accepted the insured’s word. He found it necessary, however, to complete the thorough investigation required by the California Fair Claims Settlement Practices Regulations to obtain evidence that the insured’s claims were correct and supported by substantial evidence.

His first interview, therefore, was with the landlord of the replacement dwelling. The landlord showed him the original lease which, unlike the copy in the hands of the insured, noted that he signed it at 11:30 a.m. on the Saturday before the fire. The adjuster questioned the landlord carefully in that regard since the fire was reported to have occurred at 10:12 p.m. the same night, or eleven hours after the insured signed the lease for the replacement house.

The landlord was adamant. He was a meticulous bookkeeper and always wrote down the date and time each lease is signed. He also remembered that the insured told him that he needed the house, furnished because it was a replacement for his house which burned in a fire. From that point on the truth was easy for the insurance adjuster and the insurer’s Special Investigative Unit to prove.

The insurer, as required by the California Insurance Code, reported its findings to the local fire arson investigators and provided them with copies of the lease and the statement obtained from the landlord. The fire investigators arrested the insured. He was tried and convicted of arson and insurance fraud. The court sentenced the insured to six years in state prison.

The insured was not arrested because of brilliant investigation or police work. He was arrested because he had so little respect for the insurer and the police that he covered no trails. He told a story that was almost impossible to believe after contact with the lessor. He rented a house to replace his burned out house before the fire.

From his own statements and actions, he established motive, opportunity, ability and premeditation.

He was so stupid in perpetrating this crime that even a novice adjuster who did the minimum investigation discovered the crime. The insurer celebrated the American judiciary that provided it and the insured with the justice they both deserved.

Adapted from my book Insurance Fraud Costs Everyone Available as a Kindle Book and Available at https://www.amazon.com/gp/product/B08QG3MYCR?pf_rd_r=845HWBP1C0XK5A3GZ6BQ&pf_rd_p=9d9090dd-8b99-4ac3-b4a9-90a1db2ef53b&pd_rd_r=787f0f76-2377-4ad2-9d91-df3dbda2a0e7&pd_rd_w=R9LjE&pd_rd_wg=QXi9P&ref_=pd_gw_unk

(c) 2025 Barry Zalma & ClaimSchool, Inc.

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00:12:21
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July 02, 2025
Anti-Concurrent Cause Language Required Claim Denial

Earth Movement Exclusion Effective as Major Cause of Loss

One of Many Causes of Destruction of House was Earth Movement

Post 5111

See the full video at https://lnkd.in/gQA-s4zZ and at https://lnkd.in/gujv2ZER, and at https://zalma.com/blog plus more than 5100 posts.

Anti-Concurrent Cause Language Required Claim Denial

Read the full article at https://lnkd.in/gwWkr4SS, see the full video at https://lnkd.in/gQA-s4zZ and at https://lnkd.in/gujv2ZER, and at https://zalma.com/blog plus more than 5100 posts.

Terri Lawrence sued alleging that State Farm breached an insurance contract and acted in bad faith by failing to pay benefits under the contract. The case was removed to the United States District Court based on diversity jurisdiction, and the trial was set to begin on September 8, 2025.

In Terri Lawrence v. State Farm Fire..., No. C24-4008-LTS-MAR, United States District Court, N.D. Iowa, Western Division (June 25, 2025) the USDC applied anti-concurrent cause language to dismiss suit.

SUMMARY JUDGMENT

...

00:07:46
July 01, 2025
Zalma’s Insurance Fraud Letter – July 1, 2025

See the full video at https://rumble.com/v6vkjrv-zalmas-insurance-fraud-letter-july-1-2025.html and at https://youtu.be/_rIBWqPcJDQ

ZIFL – Volume 29 No. 13 – July 1, 2025

Post 5111

Uber Technologies Inc. sued a group of lawyers, medical providers and rideshare drivers it claims staged car accidents, manufactured damages and received unnecessary medical procedures to take advantage of insurance policies in Florida, costing the rideshare giant “several million dollars” in legal fees.

Uber accused the group of conspiring to “generate an excuse to deliver unnecessary medical care, submit false insurance claims for recovery and file frivolous lawsuits to sue for non-existent damages” between 2023 and 2024. The five drivers named in the suit were “recruited with bribes to stage accidents,” Uber said in the federal suit filed in south Florida. The group recruited claimants who took their cars to designated body shops to manufacture the “false impression that the accidents resulted in injury,” the company said.

Read ...

00:09:05
June 30, 2025
Man Bites Dog Story – Allstate Sues 42 Defendants for Fraud

Lawyer Representing 35 Defendants in Fraud Case Has Insurmountable Conflict
Post 5110

Alleged Fraudsters have Obvious Conflicts with Each Other

See the full video at https://lnkd.in/gGC6FcAx and at https://lnkd.in/gJVjACnq and at https://zalma.com/blog plus more than 5100 posts.

In Allstate Insurance Company, et. al v. Robert Matturro, D.C., et al.; New Jersey Department Of Banking And Insurance, Intervenor, No. A-0711-24, Superior Court of New Jersey, Appellate Division (June 16, 2025) Allstate and several related entities sued forty-two defendants, including medical practices, their owners, administrators, and various corporate entities. The plaintiffs alleged that the defendants engaged in an insurance fraud scheme involving unlawfully structured medical practices, self-referrals, kickbacks, and medically unnecessary treatments and tests.

The Allstate plaintiffs sought damages for personal injury protection (PIP) benefits paid to the defendants, compensatory damages for investigating fraudulent bills, ...

00:09:54
May 15, 2025
Zalma's Insurance Fraud Letter - May 15, 2025

ZIFL Volume 29, Issue 10
The Source for the Insurance Fraud Professional

See the full video at https://lnkd.in/gK_P4-BK and at https://lnkd.in/g2Q7BHBu, and at https://zalma.com/blog and at https://lnkd.in/gjyMWHff.

Zalma’s Insurance Fraud Letter (ZIFL) continues its 29th 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/ You can read the full issue of the May 15, 2025 issue at http://zalma.com/blog/wp-content/uploads/2025/05/ZIFL-05-15-2025.pdf
This issue contains the following articles about insurance fraud:

Health Care Fraud Trial Results in Murder for Hire of Witness

To Avoid Conviction for Insurance Fraud Defendants Murder Witness

In United States of America v. Louis Age, Jr.; Stanton Guillory; Louis Age, III; Ronald Wilson, Jr., No. 22-30656, United States Court of Appeals, Fifth Circuit (April 25, 2025) the Fifth Circuit dealt with the ...

May 15, 2025
CGL Is Not a Medical Malpractice Policy

Professional Health Care Services Exclusion Effective

Post 5073

See the full video at https://lnkd.in/g-f6Tjm5 and at https://lnkd.in/gx3agRzi, and at https://zalma.com/blog plus more than 5050 posts.

This opinion is the recommendation of a Magistrate Judge to the District Court Judge and involves Travelers Casualty Insurance Company and its duty to defend the New Mexico Bone and Joint Institute (NMBJI) and its physicians in a medical negligence lawsuit brought by Tervon Dorsey.

In Travelers Casualty Insurance Company Of America v. New Mexico Bone And Joint Institute, P.C.; American Foundation Of Lower Extremity Surgery And Research, Inc., a New Mexico Corporation; Riley Rampton, DPM; Loren K. Spencer, DPM; Tervon Dorsey, individually; Kimberly Dorsey, individually; and Kate Ferlic as Guardian Ad Litem for K.D. and J.D., minors, No. 2:24-cv-0027 MV/DLM, United States District Court, D. New Mexico (May 8, 2025) the Magistrate Judge Recommended:

Insurance Coverage Dispute:

Travelers issued a Commercial General Liability ...

April 30, 2025
The Devil’s in The Details

A Heads I Win, Tails You Lose Story
Post 5062

Posted on April 30, 2025 by Barry Zalma

"This is a Fictionalized True Crime Story of Insurance Fraud that explains why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The story is designed to help everyone to Understand How Insurance Fraud in America is Costing Everyone who Buys Insurance Thousands of Dollars Every year and Why Insurance Fraud is Safer and More Profitable for the ­­­Perpetrators than any Other Crime."

Immigrant Criminals Attempt to Profit From Insurance Fraud

People who commit insurance fraud as a profession do so because it is easy. It requires no capital investment. The risk is low and the profits are high. The ease with which large amounts of money can be made from insurance fraud removes whatever moral hesitation might stop the perpetrator from committing the crime.

The temptation to do everything outside the law was the downfall of the brothers Karamazov. The brothers had escaped prison in the old Soviet Union by immigrating to the United...

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