To Prove Fraud Admissible Evidence is Required
Post 5200
See the full video at https://lnkd.in/g9cmMseN and at https://lnkd.in/g5eAYwdN, and at https://zalma.com/blog plus more than 5200 posts.
Allegations That Health Care Providers Assist in No Fault Fraud Escape MSJ
In NATIONWIDE GENERAL INSURANCE COMPANY, NATIONWIDE MUTUAL INSURANCE COMPANY, and any and all of their subsidiaries, affiliates and/or parent companies. Plaintiffs v. BILLEESHA BROWN, MANUEL A. CRUZ, ALGELIS TATIS, The “Individual Defendants”, et al and the “Healthcare Provider Defendants”, Index No. 618243/2023, 2025 NY Slip Op 33374(U), Motion Seq. No. 003, Supreme Court, Nassau County (September 15, 2025) dealt with a motion for summary judgment (MSJ) filed by the insurers.
Case Overview:
This is a declaratory judgment action where the plaintiff, NATIONWIDE GENERAL INSURANCE COMPANY, seeks a determination that it is not obligated to provide first-party automobile insurance coverage, including No Fault benefits and/or uninsured/underinsured motorist benefits, in connection with a motor vehicle collision alleged to have occurred on August 7, 2022.
Incident Details:
The incident involved a NATIONWIDE insured vehicle driven by BILLEESHA BROWN, with passengers MANUEL A. CRUZ and ALGELIS TATIS. The vehicle was reportedly struck in the left rear by a hit-and-run vehicle, causing BROWN to lose control and hit the highway dividers.
Plaintiff’s Arguments:
The plaintiff argued that the Individual Defendants staged and/or intentionally caused the collision and made material misrepresentations and/or omissions of fact, and false and/or fraudulent statements in presenting their claims to NATIONWIDE. The plaintiff relies on discrepancies in BROWN’s representation and EZ Pass records to suggest that the Individual Defendants were not in the insured vehicle at the time of the incident.
COURT’S FINDINGS:
The court found that the discrepancies raised suspicion but were not sufficient to establish as a matter of law that the Individual Defendants made material misrepresentations about their presence in the vehicle. The court also noted that an intentional and staged collision caused in furtherance of an insurance fraud scheme is not a covered accident under a policy of insurance.
Legal Standards:
The court referenced several cases to articulate the standard of proof required for summary judgment. The court emphasized that the plaintiff must demonstrate, prima facie, entitlement to judgment as a matter of law and the absence of any issues of material fact.
ANALYSIS
Summary Judgment Decision:
The court denied the plaintiff’s motion for summary judgment, finding that the plaintiff failed to meet the higher burden of proof required for such a motion.
The Court acknowledges that on plaintiff s prior motion for a default judgment, the Court found plaintiffs prima facie proof sufficient for purposes of granting the motion. On a motion for a default judgment, however, the defaulting defendants are deemed to have admitted all of the allegations of the complaint and all reasonable inferences to be drawn from them, and the plaintiff heed only establish that a viable cause of action exists.
The standard of proof applicable upon a motion for summary judgment seeking a determination that the insurer is not required to pay No Fault claims submitted by provider defendants has been articulated consistently by the Second Department, and is controlling authority for any determination by this Court,
It is well settled that an intentional and staged collision caused in the furtherance of an insurance fraud scheme is not a covered accident under a policy of insurance. The Court’s analysis of the evidence as it pertains to the issues of the intentional nature of the occurrence or the fraudulent presentation of the claim is set forth in entire Summary Judgment Decision and need not be repeated here. As stated by the Court in the Summary Judgment Decision, most of the alleged discrepancies in the EUO testimony of the Individual Defendants were not material to the claim and that the incident was intentional or conclusive of a material misrepresentation in the presentation of the claim.
The EZ Pass records only demonstrate the location of the second vehicle on the night in question; they do not establish who occupied the second vehicle, or that the Individual Defendants did not occupy the subject vehicle. Plaintiffs investigator makes an inferential leap that is unsupported by admissible proof. Without more, the evidence presented raises issues of fact or credibility which are appropriately determined by the trier of fact and the motion for summary judgment was rejected.
ZALMA OPINION
Nationwide, like other no-fault insurers doing business in New York lose much money as a result of fraud and staged accidents, fight back by suing those who staged the accidents and the health care providers that faked treatment of non-injured fraudsters. Nationwide proved some of the fraud because the defendants defaulted but will need to produce more evidence of fraud at trial that is more than an unsupported inferential leap of fact.
(c) 2025 Barry Zalma & ClaimSchool, Inc.
Please tell your friends and colleagues about this blog and the videos and let them subscribe to the blog and the videos.
Subscribe to my substack at https://barryzalma.substack.com/subscribe
Go to X @bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/account/content?type=all; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; Go to the InsuranceClaims Library – https://lnkd.in/gwEYk.
The Professional Claims Handler
Post 5218
Read the full article at https://www.linkedin.com/pulse/zalma-philosophy-claims-handling-part-8-barry-zalma-esq-cfe-zdwsc, see the full video at https://rumble.com/v70zl4s-the-zalma-philosophy-of-claims-handling-part-8.html and at https://youtu.be/MIYcF71ffRQ, and at https://zalma.com/blog plus more than 5200 posts.
Claims Commandment X – Thou Shall Not Pretend to be a Lawyer
Some experienced and professional claims people know the law in their area of expertise better than most lawyers.
Adjusters should be adjusters and leave lawyering to lawyers. Similarly, lawyers should be lawyers and never try to be adjusters.
Claims Commandment XI – Thou Shall Empathize With the Claimant
Everyone presenting a claim is unhappy, disturbed, shocked, injured and needs help.
Empathy is identification with and understanding of another’s situation, feelings, and motives. It is the ability to understand another person’s circumstances, point of view, thoughts, and feelings....
HOW TO CREATE AN EXCELLENCE IN CLAIMS HANDLING PROGRAM
See the full video at https://rumble.com/v70wb2i-the-zalma-philosophy-of-claims-handling-part-6.html and at https://youtu.be/tL5nDKPEs40 and at https://zalma.com/blog plus more than 5200 posts.
Post 5217
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.
An Excellence in Claims Handling program begins with a statement in the insurer’s claims manual or statement of professionalism that it is dedicated to providing excellence in claims handling to every insured who presents a claim.
The excellence in claims handling program should include, at a minimum:
A series of lectures supported by text materials explaining:
A definition of insurance.
How to read and understand an insurance policy.
How to interview an insured, witness, or claimant.
How to assist an insured in the insured’s obligation to ...
The Professional Claims Handler
Post 5216
Read the full article at https://www.linkedin.com/pulse/zalma-philosophy-claims-handling-part-5-barry-zalma-esq-cfe-jde8c, see the full video at https://rumble.com/v70q4x8-the-zalma-philosophy-of-claims-handling-part-5.html and at https://youtu.be/6b9tZQsEkB4, and at https://zalma.com/blog plus more than 5200 posts.
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.
Standards to be a Professional Claims Adjuster
The Insurance claims professional should be a person who:
1. Can read and understand the insurance policies issued by the insurer.
2. Understands the promises made by the policy.
3. Understand their obligation, as an insurer’s claims staff, to fulfill the promises made.
4. Are competent investigators.
5. Have empathy and recognize the difference between empathy and sympathy.
6. ...
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 ...
