Unjust Enrichment is an Non-Contract Remedy
Post 5158
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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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Refusal to Provide Workers’ Compensation is Expensive
Post 5240
Read the full article at https://lnkd.in/guC9dnqA, see the video at https://lnkd.in/gVxz-qmk and at https://lnkd.in/gUTAnCZw, and at https://zalma.com/blog plus more than 5200 posts.
In Illinois Department of Insurance, Insurance Compliance Department v.USA Water And Fire Restoration, Inc., And Nicholas Pacella, Individually And As Officer, Nos. 23WC021808, 18INC00228, No. 25IWCC0467, the Illinois Department of Insurance (Petitioner) initiated an investigation after the Injured Workers’ Benefit Fund (IWBF) was added to a pending workers’ compensation claim. The claim alleged a work-related injury during employment with the Respondents who failed to maintain workers’ compensation Insurance.
Company Overview:
USA Water & Fire Restoration, Inc. was incorporated on January 17, 2014, and dissolved on June 14, 2019, for failure to file annual reports and pay franchise taxes. It then operated under assumed names including USA Board Up & Glass Co. and USA Plumbing and Sewer. The business ...
Arsonist Incompetently Moves Pro Se to Avoid Prison
Post 5239
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In Christopher A. Barosh v. Morris Houser, et al., Civ. No. 22-0769, United States District Court, E.D. Pennsylvania (November 25, 2025) a convicted arsonist and insurance fraudster moved the USDC acting in Pro se filed Objections to Magistrate Judge Reid’s Recommendation that the US District Judge dismiss his § 2254 Petition to avoid jail.
BACKGROUND
In October 2005, Barosh set fire to his girlfriend’s Philadelphia home — some 25 hours before the cancellation of the property’s insurance policy. Several witnesses saw Barosh leaving the property shortly before the fire erupted. After the fire, Barosh made “two separate admissions of guilt.”
He attempted to pay an acquaintance to provide him with an alibi for the time of the arson. The eyewitnesses, brother, and ...
Conditional Release Allows Supplemental Claims
Post 5238
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A Release Should Totally Resolve Dispute
In Harvey et al. v. Hall, No. A25A1774, Court of Appeals of Georgia, Fourth Division (December 3, 2025) Paul Harvey, an employee of Arthur J. Dovers (d/b/a 3D Mobile Home Services), drove a truck towing a trailer loaded with machinery and equipment. Harvey fell asleep, veered off the road, and crashed into a culvert, causing Lamar Hall serious injuries.
FACTS OF SETTLEMENT
On August 18, 2020, Hall signed a limited liability release under OCGA § 33-24-41.1, releasing Harvey, Dovers, and their insurer (Georgia Farm Bureau Insurance Company) from liability for the accident in exchange for $50,000, “except to the extent other insurance coverage is available which covers the claim.”
Dovers’s general liability insurer (Republic-Vanguard ...
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 ...
