Man Bites Dog Story
Insurer Defeats No Fault Fraudsters
Post 5117
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In State Farm Fire And Casualty Company v. 123 Medical Group, P.C. D/B/A OPEN MRI, et al, Index No. 151183/2025, 2025 NY Slip Op 32297, Supreme Court, New York County (June 30, 2025) plaintiff sought a declaratory judgment that plaintiff is not obligated to pay no-fault benefits for the medical treatment of Darrel Branch Andy Celeste et al for injuries they allegedly sustained in a motor vehicle collision based upon plaintiffs’ founded belief that the collision at issue staged as part of an insurance fraud scheme.
DISCUSSION
In order to establish its entitlement to a default judgment plaintiff must submit proof of:
(1) service of the summons and complaint;
(2) the facts constituting the claim; and
(3) defendants’ default in answering or appearing.
Finally, plaintiff has provided proof of the facts constituting its claim through the affidavit of Micki Fraley, an employee of the Special Investigative Unit of State Farm Fire and Casualty detailing the basis for plaintiffs conclusion that the subject collision was staged.
Accordingly State Farm has no duty to provide, pay, or honor any current or future claims by 123 Medical Group, P.C. d/b/a Open MRI, and multiple other alleged health care providers.
ZALMA OPINION
Insurance Fraud takes no less than $308 Billion a year. Insurers are required by law to maintains a Special Investigative Unit (SIU) to investigate and work to defeat fraud. State Farm’s SIU found detailed evidence that a series of health care providers provided services to people involved in s fake auto accident intended to defraud State Farm and cause money to be provided to health care providers who take a lien and claim – falsely – that they provided health care to the occupants of the car in the staged accident. Since the police fail or refuse to prosecute the health care providers State Farm acted proactively to obtain a judgment they do not owe the health care providers who are violating the no-fault law.
(c) 2025 Barry Zalma & ClaimSchool, Inc.
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Payment of Appraisal Award Defeats Claim of Bad Faith
Post 5163
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Hurricane Damage to Dwelling Established by Appraisal Award
In Homeowners Of America Insurance Company v. Emilio Menchaca, No. 01-23-00633-CV, Court of Appeals of Texas, First District (July 31, 2025) after a hurricane Homeowners of America Insurance Company (“HAIC”) estimated that the cost of covered repair to Menchaca’s house was $3,688.54, which was less than his deductible, and therefore no payment would be made.
FACTS
After Menchaca retained counsel HAIC advised that, under the terms of the policy, Menchaca was required to first invoke the appraisal process prior to filing suit, and that HAIC reserved the right to request that Menchaca and any adjuster hired on his behalf submit to an Examination Under Oath (“EUO”).
On August 23, 2018, Menchaca’s counsel ...
The Quality of Insurance Fraud Perpetrators is Declining
Post 5162
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Insured Admits Fake Theft and Shows Allegedly Stolen Item to Insurance Investigator
Christie Paolino an investigator for Westfield Insurance Company testified that appellant Matthew McGrath reported the theft of his vehicle and equipment to Westfield, including the VIN for the GMC truck. Paolino met with McGrath at his residence in Cleveland. She asked if they could move to a quieter spot such as the backyard. As they walked up the driveway towards the backyard, Paolino noticed “two snowplows sitting in the driveway” and recognized one as the snowplow “that he had reported stolen.” She asked appellant “if that was, in fact, the snowplow,” and he admitting to the falsity of his claim he responded that it was.
In STATE OF OHIO v. MATTHEW MCGRATH, ...
Selling Office of US Senator is an Unforgivable Crime
Post 5161
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Go Directly to Jail, Do Not Pass Go, Claim of Innocence Unbelievable
SUMMARY OF THE CASE
Nadine Menendez, along with then-Senator Robert Menendez, Wael Hana, Jose Uribe, and Fred Daibes, was indicted for participating in a bribery scheme. The charges included conspiracy to commit bribery, honest services wire fraud, extortion under color of official right, and obstruction of justice. Both were found guilty at trial. Mrs. Menendez moved to overturn the jury verdict.
In UNITED STATES OF AMERICA v. NADINE MENENDEZ, No. (S4) 23-Cr-490 (SHS), United States District Court, S.D. New York (July 31, 2025) the USDC upheld the convictions after a lengthy analysis of issues raised by Ms. Menendez.
KEY POINTS
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Bribery and Corruption:
The evidence presented was sufficient to prove a corrupt quid pro quo involving official ...
Rulings on Motions Reduced the Issues to be Presented at Trial
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CASE OVERVIEW
In Richard Bernier v. State Farm Mutual Automobile Insurance Company, No. 4:24-cv-00002-GMS, USDC, D. Alaska (May 28, 2025) Richard Bernier made claim under the underinsured motorist (UIM) coverage provided in his State Farm policy, was not satisfied with State Farm's offer and sued. Both parties tried to win by filing motions for summary judgment.
FACTS
Bernier was involved in an auto accident on November 18, 2020, and sought the maximum available UIM coverage under his policy, which was $50,000. State Farm initially offered him $31,342.36, which did not include prejudgment interest or attorney fees.
Prior to trial Bernier had three remaining claims against State Farm:
1. negligent and reckless claims handling;
2. violation of covenant of good faith and fair dealing; and
3. award of punitive damages.
Both Bernier and State Farm dispositive motions before ...
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 ...
Professional Health Care Services Exclusion Effective
Post 5073
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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 ...
