UPCODING FRAUDSTER NEEDS TO PRODUCE DOCUMENTS DEMANDED
Post number 5282
Read the full article at https://www.linkedin.com/pulse/insurers-must-proactive-when-victims-fraud-barry-zalma-esq-cfe-07mpc, see the video at and at https://youtu.be/LxKCyb7qeZ0, and at https://zalma.com/blog plus more than 5250 posts.
Insurance Fraud Can Be Stopped by Aggressive Insurers
In Unitedhealthcare Services, Inc., United Healthcare Insurance Co., and UMR, Inc. v. Team Health Holdings, Inc., Ameriteam Services, LLC, and HCFS Health Care Financial Services, Inc., No. 3:21-CV-364-DCLC-DCP, United States District Court, E.D. Tennessee, Knoxville (February 2, 2026) Plaintiffs are health insurance providers and claim administrators who process and pay approximately one million claims daily, relying on automated adjudication and truthful information from providers.
FACTUAL BACKGROUND
Defendants, including Team Health Holdings, Inc., Ameriteam Services, LLC,...
Pro Se Plaintiff Exceeds Logic & Sense
Post number 5281
See the video at and at and at https://zalma.com/blog plus more than 5250 posts.
In Gordon Clark v. Hanover Insurance Group, et al., No. 3:24-CV-348 (SVN), United States District Court, D. Connecticut (January 30, 2026) the USDC dealt with a series of claims brought by a person representing himself resulting from an auto accident.
FACTUAL BACKGROUND
Plaintiff Gordon Clark, proceeding pro se, sued Olga L. Orengo and her insurer, The Hanover Insurance Group, Inc., following a motor vehicle collision in Windsor, Connecticut on July 22, 2023. Clark alleged that, despite Orengo being at fault, Hanover and Orengo refused to accept liability and instead filed an insurance claim asserting Clark was responsible for the accident.
LEGAL ISSUES
Clark’s Second Amended Complaint (SAC) included claims for negligence, negligent infliction of emotional distress, and ...
Pro Se Plaintiff Exceeds Logic & Sense
Post number 5281
See the video at and at and at https://zalma.com/blog plus more than 5250 posts.
In Gordon Clark v. Hanover Insurance Group, et al., No. 3:24-CV-348 (SVN), United States District Court, D. Connecticut (January 30, 2026) the USDC dealt with a series of claims brought by a person representing himself resulting from an auto accident.
FACTUAL BACKGROUND
Plaintiff Gordon Clark, proceeding pro se, sued Olga L. Orengo and her insurer, The Hanover Insurance Group, Inc., following a motor vehicle collision in Windsor, Connecticut on July 22, 2023. Clark alleged that, despite Orengo being at fault, Hanover and Orengo refused to accept liability and instead filed an insurance claim asserting Clark was responsible for the accident.
LEGAL ISSUES
Clark’s Second Amended Complaint (SAC) included claims for negligence, negligent infliction of emotional distress, and ...
Owner of Property Not Named as Insured Has No Standing
Post number 5280
See the video at https://lnkd.in/gVwMZnES and at https://lnkd.in/geUWJ5Sa, and at https://zalma.com/blog plus more than 5250 posts.
When Ownership in Property Changes it is Essential to Cause the Policy to Name the New Owner as Insured
In Joyce Lynn Serauskas v. Liberty Mutual Fire Insurance Co., No. 25-cv-12474, United States District Court, N.D. Illinois, Eastern Division (February 4, 2026) in August 2024 a fire damaged a home on West 51st Street in Chicago. Joyce Lynn Serauskas filed an insurance claim with Liberty Mutual Fire Insurance Co., under a homeowner’s policy originally issued to her mother, Estelle Bielecki, in 1978.
FACTUAL BACKGROUND
The policy had been automatically renewed every year with premiums paid on time, including at the time of the fire. However, Estelle Bielecki had passed away in 2010, and Serauskas had continued to reside in the home and pay premiums.
Eventually Serauskas acquired full ownership before the ...
You Get What You Pay For – Less Coverage Means Lower Premium
Post number 5275
Posted on January 30, 2026 by Barry Zalma
See the video at and at
When Experts for Both Sides Agree That Two Causes Concur to Cause a Wall to Collapse Exclusion Applies
In Lido Hospitality, Inc. v. AIX Specialty Insurance Company, No. 1-24-1465, 2026 IL App (1st) 241465-U, Court of Appeals of Illinois (January 27, 2026) resolved the effect of an anti-concurrent cause exclusion to a loss with more than one cause.
Facts and Background
Lido Hospitality, Inc. operates the Lido Motel in Franklin Park, Illinois. In November 2020, a windstorm caused one of the motel’s brick veneer walls to collapse. At the time, Lido was insured under a policy issued by AIX Specialty Insurance Company which provided coverage for windstorm damage. However, the policy contained an exclusion for any loss or damage directly or indirectly resulting from ...
Declaratory Relief Available to an Insurer from USDC
Post number 5274
Read the full article at https://www.linkedin.com/pulse/resolution-coverage-issues-appropriate-under-federal-barry-wfpoc, see the video at and at and at https://zalma.com/blog plus more than 5250 posts.
Insurer Seeks Limitation of Liability of Child Killed by Foster Dogs
In the Cincinnati Specialty Underwriters Insurance Company, an Ohio corporation v. Dennis Murphy, as Personal Representative of the Wrongful Death Estate of Avery Colin Jackson-Dunphy, Deceased; Patrick Admiral Dunphy, an Individual; Danika Thompson, an Individual; and Animal Services Center Of The Messila Valley, a New Mexico limited Liability Company, No. CIV 24-1039 JB/JFR, United States District Court, D. New Mexico (January 23, 2026) resolved the issues raised about the court's jurisdiction.
Cincinnati Specialty Underwriters Insurance Company ...
Posted on January 26, 2026 by Barry Zalma
Insurance Fraud Should Not be a Retirement Plan
More from Excellence in Claims Handling Substack for Subscribers Only
You’re reading, until you reach the paywall, from the free part of Excellence in Claims Handling until you reach the paywall. You should consider joining as a paid member to get full access to articles for members only, to our news, analysis, insurance coverage, claims, insurance fraud and insurance webinars, by clicking at the “subscribe” button below.
Health Insurance Providers Are Attempting Insurance Fraud to Fund Retirement
Every insurer is required by its shareholders, members, state statutes and state regulations to do everything possible to deter and defeat attempts at insurance fraud. Most insurers, therefore, have a staff of fraud investigators working under their Special Investigative Unit (SIU) and the SIU works to train the claims handlers to recognize the indicators or red flags of fraud.
Much to the surprise of...
