Unjust Enrichment is an Non-Contract Remedy
Post 5158
See the full video at https://lnkd.in/gv2iv_St and at https://lnkd.in/gdqVihMa, and at https://zalma.com/blog plus more than 5150 posts.
When an Insurer is Defrauded it Should Sue For Fraud Only
MONY Life Insurance Company v. Bernard R. Perez, No. 23-10770, United States Court of Appeals, Eleventh Circuit (July 23, 2025) resulted in a decision that allows an insured of a Disability Insurance policy to successfully defraud his insurer.
The case involved a dispute between MONY Life Insurance Company and Bernard R. Perez, an ophthalmologist, over a disability insurance contract. Perez was diagnosed with throat cancer in 2011 and began receiving monthly disability benefits from MONY. However, MONY later suspected Perez of dishonesty in his disability claims and discontinued payments in 2018.
FACTS
In 1987, ophthalmologist Bernard R. Perez formed a for-profit medical practice in Tampa, Florida. Soon thereafter, in June 1988, Perez applied for, and, in September 1988, was issued a disability insurance policy by MONY Life Insurance Company.
Perez underwent successful surgery in June 2011 and was subsequently treated with proton beam radiation therapy in July and August 2011. Since his treatment, Perez has been cancer-free. Perez submitted a disability claim form to MONY in July 2011 asserting that he was unable to work, and in August 2011 he began receiving monthly disability benefits.
KEY ISSUES
Unjust Enrichment Claim
MONY sued Perez for unjust enrichment, claiming he received benefits he was not entitled to due to misrepresentations about his medical condition and financial information. The jury initially awarded MONY $388,000, but the USCA set aside this verdict, stating that an unjust enrichment claim cannot lie when there is an express contract covering the same subject matter.
Breach of Contract Counterclaim:
Perez counterclaimed for breach of contract, arguing that MONY wrongfully stopped his benefits. The jury found in favor of MONY, and the USCA affirmed this verdict, noting that Perez had submitted false and misleading information in his proofs of loss.
ELEVENTH CIRCUIT’S CONCLUSION
MONY determined that Perez may have been dishonest in submitting basic information related to his disability and his financial condition, and, in February 2018, it discontinued making further payments to Perez.
MONY sued Perez for unjust enrichment and Perez counterclaimed for breach of contract. After a nine-day trial, during which extensive evidence established Perez’s deceitful conduct, a jury returned a verdict in favor of MONY on its unjust enrichment claim, awarding it $388,000.
At trial, MONY convincingly demonstrated that many of the business expenses submitted by Perez were untruthful. Moreover, MONY established that Perez was deceptive in reporting how many hours he worked.
After a nine-day trial, the jury ultimately determined that Perez had been unjustly enriched and that MONY did not breach the insurance contract. Accordingly, the jury awarded MONY $388,000 in damages accrued between August 2015 and January 2018.
DISCUSSION
Florida courts have held that a plaintiff cannot pursue a quasi-contract claim for unjust enrichment if an express contract exists concerning the same subject matter holding that a plaintiff cannot pursue an equitable theory, such as unjust enrichment or quantum meruit, to prove entitlement to relief if an express contract exists that covers the same topic.
MONY’s unjust enrichment claim failed under Florida law because it covers the same subject matter as the insurance contract.
While MONY attempted to amend its complaint (for the fourth time) to assert a claim for fraud, very late in the day of this protracted litigation, the district court exercised its considerable discretion in denying the motion in the interests of timing and efficiency.
The USCA concluded that the district court erred under Florida law in allowing MONY’s unjust enrichment claim to move forward. The claim should not have been sent to the jury. Accordingly, the USCA set aside the jury verdict in favor of MONY on its unjust enrichment claim and, on remand, directed the district court to vacate its judgment awarding MONY $448,930.06.
The evidence adduced at trial overwhelmingly established that Perez repeatedly submitted false and misleading information material to his proofs of loss.
ZALMA OPINION
MONY was too smart by half for its own good in this case where it had overwhelming evidence the Dr. Perez misrepresented material facts when he presented claims and proofs of loss which proof of fraud was affirmed on appeal. However, with a cause of action for the blatant fraud available to MONY it did not sue for fraud. Because MONY did not sue for fraud and its attempt to amend the complaint until its 4th attempt to amend was too late. Common law fraud would have allowed MONY to seek every dollar paid to Perez plus extracontractual damages but tried to be “nice” by only seeking non contractual relief.
(c) 2025 Barry Zalma & ClaimSchool, Inc.
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Hertz Succesfully Refuses to Pay Alleged Fraudulent Health Care Providers
Post 5222
Read the full article at https://www.linkedin.com/pulse/man-bites-dog-story-hertz-sues-alleged-fraudsters-zalma-esq-cfe-efbgc, see the video at and at and at https://zalma.com/blog plus more than 5200 posts.
Proactive Victim of Fraud Defeats Health Care Providers
In Hertz Vehicles, LLC v. Alignment Chiropractic, P.C., et al, Index No. 157368/2024, 2025 NY Slip Op 33627(U), Motion Seq. No. 001, NYSCEF Doc. No. 46, Supreme Court, New York County (September 30, 2025) Plaintiff alleged it is not obligated to pay no-fault benefits for the medical treatment of defendants for injuries while occupants of a 2023 Hyundai, owned and self-insured by Hertz.
FACTUAL BACKGROUND
Plaintiff moved for a default judgment against defendants Alignment Chiropractic, P.C., and many other alleged health care providers.
Plaintiff also ...
Hertz Succesfully Refuses to Pay Alleged Fraudulent Health Care Providers
Post 5222
Read the full article at https://www.linkedin.com/pulse/man-bites-dog-story-hertz-sues-alleged-fraudsters-zalma-esq-cfe-efbgc, see the video at and at and at https://zalma.com/blog plus more than 5200 posts.
Proactive Victim of Fraud Defeats Health Care Providers
In Hertz Vehicles, LLC v. Alignment Chiropractic, P.C., et al, Index No. 157368/2024, 2025 NY Slip Op 33627(U), Motion Seq. No. 001, NYSCEF Doc. No. 46, Supreme Court, New York County (September 30, 2025) Plaintiff alleged it is not obligated to pay no-fault benefits for the medical treatment of defendants for injuries while occupants of a 2023 Hyundai, owned and self-insured by Hertz.
FACTUAL BACKGROUND
Plaintiff moved for a default judgment against defendants Alignment Chiropractic, P.C., and many other alleged health care providers.
Plaintiff also moved...
Who’s on First? State or Federal Court
Post 5222
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Conflict Between State & Federal Court Requires Abstention
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Conflict Between State & Federal Court Requires Abstention
Hector David Campoverde was injured at a Brooklyn construction site in 2015. Campoverde was an employee of Vazquez Bro Restoration Inc., a subcontractor for C.C.C. Renovation Inc., which was itself a subcontractor for general contractor L&M Builders Group LLC. In Starr Indemnity & Liability Company v. Scottsdale Insurance Company, No. 24-CV-3309 (PKC) (TAM), United States District Court, E.D. New York (September 30, 2025) was asked to determine whether one or more of the involved insurers is obligated to indemnify Campoverde, and in what order Camporverde can receive indemnity, from one or more insurer.
Underlying Incident:
Campoverde sued the ...
The Professional Claims Handler
Post 5219
Posted on October 31, 2025 by Barry Zalma
An Insurance claims professionals should be a person who:
Can read and understand the insurance policies issued by the insurer.
Understands the promises made by the policy.
Understand their obligation, as an insurer’s claims staff, to fulfill the promises made.
Are competent investigators.
Have empathy and recognize the difference between empathy and sympathy.
Understand medicine relating to traumatic injuries and are sufficiently versed in tort law to deal with lawyers as equals.
Understand how to repair damage to real and personal property and the value of the repairs or the property.
Understand how to negotiate a fair and reasonable settlement with the insured that is fair and reasonable to both the insured and the insurer.
How to Create Claims Professionals
To avoid fraudulent claims, claims of breach of contract, bad faith, punitive damages, unresolved losses, and to make a profit, insurers ...
The History Behind the Creation of a Claims Handling Expert
The Insurance Industry Needs to Implement Excellence in Claims Handling or Fail
Post 5210
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry. This statement of my philosophy on claims handling starts with my history as a claims adjuster, insurance defense and coverage lawyer and insurance claims handling expert.
My Training to be an Insurance Claims Adjuster
When I was discharged from the US Army in 1967 I was hired as an insurance adjuster trainee by a professional and well respected insurance company. The insurer took a chance on me because I had been an Army Intelligence Investigator for my three years in the military and could use that training and experience to be a basis to become a professional insurance adjuster.
I was initially sat at a desk reading a text-book on insurance ...
The History Behind the Creation of a Claims Handling Expert
The Insurance Industry Needs to Implement Excellence in Claims Handling or Fail
Post 5210
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry. This statement of my philosophy on claims handling starts with my history as a claims adjuster, insurance defense and coverage lawyer and insurance claims handling expert.
My Training to be an Insurance Claims Adjuster
When I was discharged from the US Army in 1967 I was hired as an insurance adjuster trainee by a professional and well respected insurance company. The insurer took a chance on me because I had been an Army Intelligence Investigator for my three years in the military and could use that training and experience to be a basis to become a professional insurance adjuster.
I was initially sat at a desk reading a text-book on insurance ...
