Zalma's Insurance Fraud Letter - December 1, 2024

ZIFL Volume 28 No. 22

Post 4939

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The Source for the Insurance Fraud Professional https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf

Zalma’s Insurance Fraud Letter (ZIFL) continues its 28th year of publication dedicated to those involved in reducing the effect of insurance fraud. ZIFL is published 24 times a year by ClaimSchool and is written by Barry Zalma. It is provided FREE to anyone who visits the site at http://zalma.com/zalmas-insurance-fraud-letter-2/ This issue contains the following articles about insurance fraud:

The EUO is a Material Condition Precedent
A Key Tool in the Effort to Reduce Fraud
Claim Properly Denied for Refusal to Testify at EUO

I spoke recently at the Conference of the Southern California Fraud Investigators Association on the Examination Under Oath as a tool to help insureds prove their losses and what happens when an insured fails or refuses to testify. This case emphasizes the purpose of my talk.

Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf

Thanksgiving Wishes from the Zalma Family

My family and I have much to be thankful for this year. My first born daughter, Stephanie Zalma, continues to care for my wife 24 hours a day 7 days a week with love and patience as Thea continues as Nana to our two grandchildren and the loving mother of our three children.

After receiving a new Aortic Heart Valve I am personally in good health, walking about 25 miles a week. Exercising my, apparently unusual mode of retirement, I work only six to eight hours a day doing what I love the most, writing about insurance, insurance claims, insurance law and acting as an insurance claims consultant and expert witness.

Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf

More McClenny Moseley & Associates Issues

This is ZIFL’s thirty eighth installment of the saga of McClenny, Moseley & Associates and its problems with the federal courts in the State of Louisiana and what appears to be an effort to profit from what some Magistrate and District judges may be criminal to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana.

Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf

Ethical Behavior & Insurance

Insurance, from the time of its first agreement to the present day has always been a business requiring ethical behavior between the insurer and the insured and between the insured and the insurer.

The concept of ethical behavior refers to well-founded standards of right and wrong that prescribe what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues, all of which are essential to the lawyer.

Ethics refers to those standards that impose the reasonable obligations to refrain from murder, rape, theft, assault, slander, and fraud. Ethical standards also include those that imply virtues of honesty, compassion, and loyalty.

There are rights presumed to exist such as those described in the Declaration of Independence submitted to King George of England in 1776 that held:

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of happiness.

The unalienable rights also include the right to life, the right to freedom from injury, and the right to liberty. Such standards are adequate standards of ethics because they are supported by consistent and well-founded reasons.

Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf

Health Insurance Fraud Convictions

Michigan Woman Convicted of $1.4M Health Care Kickback Scheme

Mary Smettler-Bolton, 71, of Oakland County, Michigan was convicted November 22, 2024 for her role in a conspiracy to defraud the United States and receive illegal health care kickbacks.

According to court documents and evidence presented at trial, Mary referred Medicare beneficiaries to several Metro Detroit home health companies in exchange for hundreds of thousands of dollars in kickbacks paid by the owners and operators of the home health companies. Over the course of four years, she and her co-conspirators caused over $1.4 million of loss to Medicare.

Smettler-Bolton was convicted of one count of conspiracy to defraud the United States and receive illegal health care kickbacks and one count of violating the federal Anti-Kickback Statute. She is scheduled to be sentenced on March 3, 2025, and faces a maximum penalty of five years in prison on the conspiracy count and a maximum penalty of 10 years in prison on the kickback count. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

Read the full article about dozens more convictions at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf

Convictions of Other Than Health Insurance Fraud

Creative Fraudster Guilty of $229K Insurance Fraud Schemes

Justin Mack, a native of Buffalo, New York, and a resident of Cleveland, Ohio, was sentenced on November 25, 2024 in the Cuyahoga County Court of Common Pleas. Mack, an Ohio man was sentenced to five years in prison and ordered to pay restitution for filing 24 fraudulent claims with multiple insurance companies, totaling more than $229,000.

An extensive investigation uncovered Mack’s pattern of submitting altered documentation, falsified claims, and using other people’s identities to fraudulently secure payouts from multiple insurance companies.

Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf

The Examination Under Oath Is Not Part of a Judicial Process

Although the EUO is a formal proceeding it is not part of a judicial process nor is it subject to the rules set out by codes of civil procedure. There is no right to object to questions and never a judge present to rule on the objections. The testimony at the EUO is required to be presented in accordance with the obligation imposed on an insured to deal fairly and in good faith with the insurer.

Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf

Barry Zalma

Barry Zalma, Inc., 4441 Sepulveda Boulevard, CULVER CITY CA 90230-4847, 310-390-4455. Subscribe to Excellence in Claims Handling at https://barryzalma.substack.com/welcome. Write to Mr. Zalma at [email protected]; https://www.zalma.com; https://zalma.com/blog. He publishes daily articles at https://zalma.substack.com, Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ to consider more than 50 volumes written by Barry Zalma on insurance and insurance claims handling.

Go to Zalma’s Insurance Fraud Letter at https://zalma.com/zalmas-insurance-fraud-letter-2/; Go to X @bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ and GTTR at https://gettr.com/@zalma