Ambiguous Policy Language Forces Insurer to Pay Losses It Did not Intend to Cover. Read the full article at https://lnkd.in/gU_Q_GMb and see the full video at https://lnkd.in/gj3hmxzn and at https://lnkd.in/gnNnseZZ and at https://zalma.com/blog plus more than 4600 posts.

If Insurer Agrees to Defend Insured May Not Expect it to Pay Independent Counsel. Read the full article at https://lnkd.in/gyrNu5yF and see the full video at https://lnkd.in/gwjHBdsA and at https://lnkd.in/g4UUw_rGhttps://lnkd.in/g4UUw_rG and at https://zalma.com/blog plus more than 4600 posts.

Insurance Fraud Charges Against Defense Counsel Does Not Result in Reversal for Ineffective Counsel. Read the full article at https://lnkd.in/g4pxuZGN and see the full video at https://lnkd.in/giHV3gwe and at https://lnkd.in/gFFZxyRP and at https://zalma.com/blog plus more than 4600 posts.

Read the full article at https://lnkd.in/gPhapwCP and see the full video at https://lnkd.in/gTEtHPYS and at https://lnkd.in/ge_9CjNk and at https://zalma.com/blog plus more than 4600 posts.

Insurance Fraud Scheme Born After Business Failure. Read the full article at https://lnkd.in/g6P2Guvr and see the full video at https://lnkd.in/gzpYtuDp and at https://lnkd.in/gE_ruhfY and at https://zalma.com/blog plus more than 4600 posts.

ANTI-SLAP MOTION FAILS BECAUSE PLAINTIFF NOT A PUBLIC FIGURE. Read the full article at https://lnkd.in/gGb7V9cZ and see the full video at https://lnkd.in/gUdSWZBE and at https://lnkd.in/gr2CNv2j and at https://zalma.com/blog plus more than 4600 posts.

“Runner” Must Pay Restitution to Insurers Barry Zalma Sep 4, 2023 Read the full article at https://lnkd.in/g4rByHpk and see the full video at https://lnkd.in/gumTEMhP and at https://lnkd.in/g86rA7p7 and at https://zalma.com/blog plus more than 4600 posts. Posted on September 4, 2023 by Barry Zalma The Eighth Circuit was called upon to decide the amount of restitution owed by a participant in a recruitment-and-kickback scheme aimed at defrauding automobile-insurance companies. The district court ordered restitution for every chiropractic patient that Abdisalan Hussein recruited from 2013 onward. In United States of America Plaintiff v. Abdisalan Abdulahab Hussein, also known as Abdisalan A. Hussein, No. 22-1275, United States Court of Appeals, Eighth Circuit (August 23, 2023) the Eighth Circuit resolved the dispute. Background Hussein ended up at a Twin Cities chiropractic clinic after an automobile accident. The visit resulted in a job: the clinic hired him to recruit patients. And then another one did too. Hussein’s role was to bring in as many accident victims as possible. Each new patient could undergo treatment up to $20,000, the limit of basic economic benefits available under most Minnesota automobile-insurance policies. In return, Hussein received a kickback of up to $1,500, a portion of which he shared with patients who returned for multiple visits. The U.S. Government started “Operation Backcracker,” targeting insurance fraud. If Hussein “qualified as [a] ‘runner’ [under Minnesota law], then insurers had no obligation to reimburse the clinic[s] for any services provided.” After a jury trial, the district court ordered Hussein to pay restitution to the insurance companies he defrauded. He complained, alleging he was not a “runner.” Because of Minnesota statutory law, the Eighth Circuit explained that not all recruiters are runners and restitution only applied to runners. On remand, the amount of restitution decreased. This time, the district court concluded that Hussein qualified as a runner for only 53 of the 65 victims, which dropped the award to $155,864. Hussein, for his part, has adopted an all-or-nothing strategy: he does not believe he owes a single penny of restitution. ANALYSIS The linchpin of Hussein’s argument is that he was never a runner. Once runners are involved, it taints the relationship and automatically relieves insurers of their duty to pay. In statutory terms, once a runner recruits someone, every health-care service provided afterward becomes “non-compensable and unenforceable as a matter of law.” A runner is someone who “directly procures or solicits prospective patients” for “pecuniary gain” and “knows or has reason to know that the provider’s purpose” is to “obtain . . . benefits under or relating to” an automobile-insurance contract. Hussein had an active role in recruiting accident victims. He also helped coach patients to deceive insurance companies all in an effort to line his own pockets. The trial record completes the picture. Hussein received up to $1,500 per patient he recruited, which satisfies the pecuniary-gain requirement. A series of text messages establishes the remaining elements. In one, Hussein texted with a clinic owner about how one patient was “a piece of shit” for not coming to enough appointments. The Eighth Circuit concluded that Hussein “directly procure[d]” these patients with at least a “reason to know,” if not actual knowledge, that the provider’s purpose was to obtain benefits under an automobile-insurance contract. The problem for Hussein is that the government met its ultimate burden of proving the loss. In a fraud case, the government bears the burden of proving a prima facie case that each victim was entitled to restitution, and the defendant bears the burden of rebutting it. One patient who testified that she called him about chiropractors even though she did not know him while he referred to another as “a piece of shit” for ending her visits. Neither were friends. And it goes without saying that being a “helpful person” in the Somali community does not transform every interaction into one “made in a social setting.” The judgment of the district court was affirmed ZALMA OPINION The crime of insurance fraud is destroying the ability of the insurance industry to serve the public and make a small profit. “Runners” called “cappers” in other states are the first level of many insurance fraud schemes. Hussein used his involvement in the Minnesota Somali community to allow unscrupulous medical providers to defraud insurers. The court, applying the strange Minnesota statute required Hussein to make restitution to most of the insurers he defrauded and put a small dent in auto insurance fraud in Minnesota. One can only hope they also convicted the health care providers and made them pay restitution as well. (c) 2023 Barry Zalma & ClaimSchool, Inc.

Zalma's Insurance Fraud Letter - September 1, 2023. Read the full article at https://lnkd.in/gtkirss4 and see the video at https://lnkd.in/gXtgJmxf and at https://lnkd.in/gU2RqPv7 and at https://zalma.com/blog plus more than 4600 posts.

ShareLeave a commentGet a group subscriptionRead the full article at https://lnkd.in/gk5ENHMu and see the full video at https://lnkd.in/gTxMzqsy and at https://lnkd.in/gW54HWmJ and at https://zalma.com/blog plus 4600 posts.

Premature Denial for Failure to Appear at EUO Fails. It is not Reasonable to Deny a Claim for Failure to Appear for EUO Before the Date the EUO was Scheduled to Occur. In March 2021, an arsonist destroyed a building on the Brockton Fair fairgrounds known as the “State Building,” owned by BAS Holding Corporation (“BAS”) and, according to BAS, insured against loss by Philadelphia Indemnity Insurance Company (“Philadelphia”). Philadelphia undertook an investigation to determine coverage. The insurer sought an examination under oath (“EUO”) of George Carney, the president and owner of BAS, scheduled the EUO and denied the claim before the scheduled date.

Steven and Nancy Taylor appealed the trial court’s granting defendant Lake Michigan Insurance Company’s motion for summary disposition and dismissing their case and the court’s denial of their motion for reconsideration. In Steven G S Taylor and Nancy Taylor v. Lake Michigan Insurance Company, No. 360974, Court of Appeals of Michigan (August 24, 2023) the plaintiffs alleged the agent should have required higher policy limits for the replacement of their log home.

McCann Plumbing, Heating & Cooling, Inc.; Andrew R. McCann; and Wendy McCann, sued defendant, Pekin Insurance Company, for breach of an insurance contract and sought declaratory judgment because the demolition of an adjacent building damaged the McCann's building.

Bad Men Must Serve the Time for Crimes from Insurance Fraud to Murder. After a multiple-count indictment against dozens of members of the Gangster. Disciples five of them, Alonzo Walton, Kevin Clayton, Donald Glass,

This case arose out of an accident that occurred in 2019. Plaintiff was hit. by a car at around 8:15 p.m. while riding a bicycle in Flint, Michigan. Plaintiff sustained serious injuries, including multiple broken bones.

Man Bites Dog Story – Allstate May Sue on Behalf of State for Insurance Fraud. Allstate Insurance Company and several of its affiliates (collectively, Allstate) brought qui tam actions on behalf of the State of California alleging insurance fraud under the California Insurance Frauds Prevention Act (IFPA) (Ins. Code, § 1871 et seq.) and the Unfair Competition Law (UCL) (Bus. &Prof. Code, § 17000 et seq.) against three medical corporations, a medical management company and its parent company, four physicians, and Sattar Mir, an individual.

Waiver of Sovereign Immunity Does Not Apply to Federal Statutory Claims. The doctrine of sovereign immunity is an “ancient” concept. It is the long-established view that a sovereign, such as a state, is “infallible,” and, thus, immune from suit “absent the State’s consent.” The General Assembly provided such consent in the Maryland Tort Claims Act which waives the State’s immunity.

This is a fictionalized True Crime Story of Insurance Fraud from an Expert who explains why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The stories help to Understand How Insurance Fraud in America is Costing Everyone who Buys Insurance Thousands of Dollars Every year and Why Insurance Fraud is Safer and More Profitable for the ­­­Perpetrators than any Other Crime. The names, and places have been changed to protect the Guilty.

INSURER’S INSTIGATION OF SETTLEMENT IS EVIDENCE OF GOOD FAITH. After parties to a suit resolved the suit by settlement one or more of the parties tried to renege on the agreement and appealed the trial court’s order to enforce the parties’ settlement agreement. The parties’ settlement agreement required them to dismiss all claims, counterclaims, and crossclaims with prejudice. In Shorewood Forest Utilities, Inc. v. Rex Properties, LLC and Don Blum, No. 22A-PL-2345, Court of Appeals of Indiana (August 11, 2023) the Court of Appeals resolved the claims concerning the Settlement Agreement.

Experienced Lawyer Claiming Ignorance of Law Is No Defense. Robert Irving Slater was a practicing worker’s compensation attorney when he entered into an agreement with the owner of USA Photocopy who paid a third party to perform intake interviews with clients of defendant’s practice, saving a significant amount of his lawyer’s own employees time and money. In exchange, defendant used USA Photocopy’s services during all workers’ compensation proceedings on those cases.

Ralph Young owned and lived on a seventy-four-foot motor operated vessel named the SUMMER STAR (“the vessel”). Mr. Young insured the vessel with Yachtinsure Services, Inc. from 2013 through 2019. On August 28, 2019, the vessel ran aground and was destroyed when Hurricane Dorian hit St. Thomas in the United States Virgin Islands, where the vessel was moored. Yachtinsure rejected the abandonment and denied Mr. Young’s claim, based on what it considered his material misrepresentations in his April 2019 policy renewal application.