Victims of Fraud Should Always Fight Back Proactively
Post 5398
Posted on July 21, 2026 by Barry Zalma
Cross-Claim Against Fraudsters Successful
In Dual Diagnosis Treatment Center, Inc., et al. v. Health Net, Inc., et al., Health Net Life Insurance Company, B331260, California Court of Appeals, Second District, Third Division (July 16, 2026) a trial verdict in favor of Health Net and against Sovereign, a network of mental health and substance use disorder treatment centers, and Health Net, Inc., Health Net of California, Inc., Health Net Life Insurance Company, and Managed Health Network, Inc. (collectively, Health Net) was appealed to the California Court of Appeals.
FACTUAL BACKGROUND
Between 2014 and 2016, Sovereign submitted claims to Health Net for medical care provided to more than 400 patients. Health Net paid some claims but rejected many others. Sovereign, as the patients' assignee, sued Health Net for breach of contract, insurance bad faith, and breach of the Employee Retirement Income Security Act of 1974 (ERISA).
Health Net cross-claimed for fraud, intentional interference with contractual relations, and unfair competition, among other things.
Health Net paid some claims but rejected many others. Health Net alleged Sovereign carried out a broad insurance-fraud scheme involving illegal patient referral fees, false residency information, premium payments and cost-sharing waivers concealed from Health Net, unnecessary services, falsified records, and inflated billing.
Before trial, the court found Sovereign had paid unlawful referral fees for more than 300 patients. After a seven-week jury trial and a later bench trial on equitable claims, judgment was entered for Health Net, including substantial damages and restitution against Sovereign and Dr. Sharma.
LAW:
The court applied California rules governing summary adjudication, the Unfair Competition Law (UCL), Insurance Code section 750, unclean hands, fraud, insurance bad faith damages, ERISA exhaustion principles, and appellate prejudice. A UCL plaintiff must show economic injury and loss of money or property but need not prove a precise amount at the standing stage.
The UCL may reach unlawful, unfair, or fraudulent business practices. The unclean-hands doctrine may bar relief in legal and equitable actions when the plaintiff’s misconduct directly relates to the transaction at issue and makes recovery inequitable.
Civil judgments are not reversed for procedural, evidentiary, instructional, or damages-related error absent a showing of prejudice.
DISCUSSION:
On appeal, Sovereign challenged the pretrial UCL ruling, the summary adjudication of Health Net’s fraud and unclean-hands defenses, several jury instructions, exclusion of California Department of Insurance materials, the ruling limiting bad-faith damages, and the judgment on ERISA claims.
The Court of Appeal emphasized that Sovereign’s briefing failed to fairly summarize the extensive trial record, limiting appellate review. The court held that any possible error in the pretrial UCL ruling was harmless because the trial court later found, after trial, an independent basis for restitution under the unfair and fraudulent prongs of the UCL. It also concluded Sovereign failed to show error in the unclean-hands ruling, because the illegal referral payments directly related to the claims for payment arising from those same referred patients.
ANALYSIS:
The decision turned on Sovereign’s inability to show reversible prejudice. The appellate court repeatedly held that even if certain rulings were questionable, Sovereign did not demonstrate a reasonable probability of a more favorable result.
The unclean-hands holding is especially important because it allowed the court to bar recovery by the assignee based on the assignee’s own misconduct, even though the patients themselves were not alleged to have acted wrongfully.
The court also treated the trial findings of pervasive fraudulent business practices as supporting restitution beyond the patients obtained through illegal referral fees.
CONCLUSION
Sovereign admitted that it paid consultants for patient referrals, but contended that the practice was lawful and known to Health Net. Sovereign thus urged that Health Net was not harmed by the payment of referral fees because it would have been responsible for claims in the same amounts even if treatment had been rendered by other providers.
The Court of Appeal affirmed the judgment in full. Sovereign did not establish prejudicial error as to the UCL ruling, unclean-hands defense, jury instructions, evidentiary exclusions, Brandt-fee ruling, or ERISA claims. In addition Respondents were awarded appellate costs.
ZALMA OPINION
People who have perpetrated insurance fraud and deceived their clients have the unmitigated gall to sue the clients they were defrauding. Usually, the victims will defend aggressively or seek to negotiate a settlement. Healthnet did not settle, did not negotiate, it cross-claimed and established the unlawful conduct, an action that worked and took the profit out of the fraud and attempted fraud.
(c) 2026 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://gbarryzalma.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://Cwww.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; Go to the InsuranceClaims Library – https://lnkd.in/gwEYk.
Insurance Expert May Not Testify to Speculative and Contains Unsupported Conclusions.
Posted on September 18, 2026 by Barry Zalma
See the full video at and at https://rumble.com/v7fmifw-expert-may-only-testify-to-what-experience-supports.html
In Michele A. Over, and The Estate Of Paul R. Over v. State Farm Mutual Automobile Insurance Company, and State Farm Fire And Casualty Company, Civil Action No. 23-cv-02243-PAB-STV, United States District Court, D. Colorado (September 14, 2026) Michele and Paul Over sued State Farm Fire and State Farm Auto over hail-damage and stolen-vehicle claims.
The operative dispute concerned State Farm Auto’s motion to exclude or limit opinions from plaintiffs’ insurance-industry expert, Aaron Castillo. Castillo.
Law
The proponent of expert testimony must establish by a preponderance of the evidence that an expert is qualified and that the opinions are helpful, sufficiently grounded, and reliably derived and applied. Experience-based opinions must explain how the...
150 Months in Prison for Tax Fraud
Post 4846
Posted on September 17, 2026 by Barry Zalma
See the full video at https://lnkd.in/g8rh3JBX and https://lnkd.in/gmkdy-9C, In United States Of America v. Thomas Addaquay, Nos. 25-10609, 25-10611, United States Court of Appeals, Eleventh Circuit (September 9, 2026) the Eleventh Circuit affirmed all challenged convictions, the 150-month aggregate sentence, and the challenged $4,123,474.55 restitution award.
FACTS
In United States Of America v. Thomas Addaquay, United States Of America v. Thomas Addaquay, Nos. 25-10609, 25-10611, United States Court of Appeals, Eleventh Circuit (September 9, 2026) the Eleventh Circuit affirmed all challenged convictions, the 150-month aggregate sentence, and the challenged $4,123,474.55 restitution award.
FACTS
Thomas Addaquay controlled United Consolidated Accounting and Business Services (UC), nominally a check-cashing business.
The government proved a three-stage tax-refund scheme that converted the resulting refund checks into usable funds through ...
Major Fraud Perpetrator Asserts Fifth Amendment Privilege to Avoid Prosecution
Post 5489
Posted on September 14, 2026 by Barry Zalma
Fraudster Refuses to Answer Questions About His Alleged Fraud
See the full video at https://lnkd.in/gvicAMDr and at https://lnkd.in/gvicAMDr
In Great American Insurance Co. v. Gemstone Property Management, LLC, et al., No. 23-cv-9100 (LJL), United States District Court, S.D. New York (September 8, 2026) Great American Insurance Company alleged that it was defrauded through a scheme in which Subin Associates, LLP recruited individuals to stage construction-site injuries, arranged unnecessary medical treatment and litigation funding, and pursued fraudulent personal-injury claims.
Luis Manuel Garcia Salcedo, resulted in a $6 million settlement. Non-party Jose Hernandez allegedly worked as an assistant manager at Subin, operated Hernandez Associates, and owned litigation-funding companies that shared office space with Subin and provided services to its clients.
After Great American ...
Sentence for Stealing from Veterans Administration Reasonably Considers State Insurance Fraud & Arson Convictions
Post 4863
Posted on October 14, 2026 by Barry Zalma
In United States Of America v. Anthony Curtis Brewer, No. 26-10745, United States Court of Appeals, Eleventh Circuit (October 8, 2026) Anthony Curtis Brewer became the fiduciary for an incapacitated recipient of Department of Veterans Affairs survivor benefits and agreed to use her funds solely for her care and support without commingling them with his own.
The VA determined that he misused $67,232.33 and removed him as fiduciary in 2022. Brewer pleaded guilty to theft of more than $1,000 in government property under 18 U.S.C. § 641. At sentencing, the district court attributed $53,567 in loss to him, producing an advisory Guidelines range of 15 to 21 months.
Citing the victim’s vulnerability, Brewer’s attempts to avoid responsibility, and his other fraudulent conduct — including state convictions for arson and insurance fraud — the court ...
Title Insurance Only Insures Real Property
Posted on October 13, 2026 by Barry Zalma
When a Seller Advised it Could Not Obtain Title to the Home Fraud Can’t be Proved
A Manufactured Home is Personal Property Until it Becomes Real Property
Post 4862
In Dale Johnson and Rose Johnson, Husband and Wife v. Stewart Title Guaranty Co., and Lennar Mortgage, LLC; Low Va Rates, LLC; Sandpoint Title Insurance, Inc.; Village Capital & Investment, LLC; and David Cassel, Engineer Agent; and Unknown Does 1-50, inclusively, No. 53126, Court of Appeals of Idaho (October 9, 2026) Dale and Rose Johnson purchased Idaho real property in 2012 with a manufactured home on it. Their purchase addendum acknowledged that the seller could not obtain title to the home, that evidence of title and an ALTA-7 endorsement might not be available, and that they accepted the home “as is.”
In 2020, after a HELOC application was denied, the Johnsons learned that the home had been wrecked and decertified in 2004 and that its 2006 conversion to real ...
Denial Of Mental Health Diversion And Probation Condition Were Affirmed
Posted on October 9, 2026 by Barry Zalma
Post 4860
In The People v. Nicholas Daniel Stiles, A173483, A173646, California Court of Appeals, First District, Second Division (September 29, 2026) Nicholas Daniel Stiles pleaded no contest to one count of insurance fraud arising from his purchase of automobile insurance after a June 2021 collision, and to grand theft arising from an April 2024 incident at a 7-Eleven.
In both cases, the trial court suspended imposition of sentence and placed him on two years’ probation. Before the pleas, Stiles sought mental health diversion in both matters and filed a written motion seeking substitute appointed counsel. The diversion applications were denied, and the court never held a hearing on the motion.
LAW
Penal Code section 1001.36 permits pretrial mental health diversion when a defendant is eligible and suitable and the proposed treatment will meet the defendant’s specialized needs; denial is reviewed for ...
