• When Rejected in Writing no UM/UIM Coverage

    Read the full article at https://lnkd.in/gwt49KRg, see the full video at https://lnkd.in/ggwkMJ_U and at https://lnkd.in/gbFpkHtK and https://zalma.com/blog plus more than 4900 posts.

    When Rejected in Writing no UM/UIM Coverage
    Post 4939

    Karina Monasterio appealed the district court’s judgment in favor of Progressive Express Insurance Company on Progressive’s complaint for declaratory judgment and Monasterio’s counterclaim against Progressive, and in favor of Rasier-DC, LLC and Uber Technologies, Inc. on her crossclaim against those defendants.

    In Progressive Express Insurance Company v. Karina Monasterio, Uber Technologies, Inc., Rasier – DC, LLC, No. 24-11256, United States Court of Appeals, Eleventh Circuit (November 18, 2024) the Eleventh Circuit affirmed the USDC.

    FACTS

    Progressive sued for declaratory judgment.

    Monasterio counterclaimed seeking a declaration that Florida’s TNC Act required Progressive, Rasier-DC, and Uber to provide uninsured motorist coverage for her accident.

    Florida’s TNC Act required insurance coverage may be maintained by the TNC, the TNC driver, or the TNC vehicle owner, or it may be provided by a combination of their policies.

    FLORIDA UM/UIM COVERAGE REQUIREMENTS

    Florida Statutes provide that no motor vehicle liability insurance policy which provides bodily injury liability coverage shall be delivered or issued for delivery in this state with respect to any “specifically insured or identified motor vehicle” registered or principally garaged in this state unless uninsured motor vehicle coverage is provided therein or supplemental thereto.

    Neither Rasier-DC nor any other named insured paid the premium for uninsured motorist coverage.

    THE APPEAL

    The Eleventh Circuit concluded that the statutory text is clear. The policy was not issued for any “specifically insured or identified motor vehicle” registered or garaged in Florida. So, the requirements of the statute did not apply.

    Because statute did not require uninsured motorist coverage for the auto insurance policy the TNC Act did not.

    ZALMA OPINION

    It is always important for a court to read the language of the applicable statute and the policy to determine coverage on an automobile insurance policy. Here the TNC, Raiser-DC rejected UM/UIM coverage and coverage was clearly not required by the statute. The only question I have is why the parties thought it was worth their time and effort to appeal to the Eleventh Circuit.

    (c) 2024 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://lnkd.in/gmmzUVBy
    Go to X @bzalma; Go to the Insurance Claims Library – https://lnkd.in/gwEYk
    When Rejected in Writing no UM/UIM Coverage Read the full article at https://lnkd.in/gwt49KRg, see the full video at https://lnkd.in/ggwkMJ_U and at https://lnkd.in/gbFpkHtK and https://zalma.com/blog plus more than 4900 posts. When Rejected in Writing no UM/UIM Coverage Post 4939 Karina Monasterio appealed the district court’s judgment in favor of Progressive Express Insurance Company on Progressive’s complaint for declaratory judgment and Monasterio’s counterclaim against Progressive, and in favor of Rasier-DC, LLC and Uber Technologies, Inc. on her crossclaim against those defendants. In Progressive Express Insurance Company v. Karina Monasterio, Uber Technologies, Inc., Rasier – DC, LLC, No. 24-11256, United States Court of Appeals, Eleventh Circuit (November 18, 2024) the Eleventh Circuit affirmed the USDC. FACTS Progressive sued for declaratory judgment. Monasterio counterclaimed seeking a declaration that Florida’s TNC Act required Progressive, Rasier-DC, and Uber to provide uninsured motorist coverage for her accident. Florida’s TNC Act required insurance coverage may be maintained by the TNC, the TNC driver, or the TNC vehicle owner, or it may be provided by a combination of their policies. FLORIDA UM/UIM COVERAGE REQUIREMENTS Florida Statutes provide that no motor vehicle liability insurance policy which provides bodily injury liability coverage shall be delivered or issued for delivery in this state with respect to any “specifically insured or identified motor vehicle” registered or principally garaged in this state unless uninsured motor vehicle coverage is provided therein or supplemental thereto. Neither Rasier-DC nor any other named insured paid the premium for uninsured motorist coverage. THE APPEAL The Eleventh Circuit concluded that the statutory text is clear. The policy was not issued for any “specifically insured or identified motor vehicle” registered or garaged in Florida. So, the requirements of the statute did not apply. Because statute did not require uninsured motorist coverage for the auto insurance policy the TNC Act did not. ZALMA OPINION It is always important for a court to read the language of the applicable statute and the policy to determine coverage on an automobile insurance policy. Here the TNC, Raiser-DC rejected UM/UIM coverage and coverage was clearly not required by the statute. The only question I have is why the parties thought it was worth their time and effort to appeal to the Eleventh Circuit. (c) 2024 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://lnkd.in/gmmzUVBy Go to X @bzalma; Go to the Insurance Claims Library – https://lnkd.in/gwEYk
    LNKD.IN
    When Rejected in Writing no UM/UIM Coverage
    When Rejected in Writing no UM/UIM Coverage Post 4939 Posted on November 26, 2024 by Barry Zalma See the full video at https://rumble.com/v5sz2eb-when-rejected-in-writing-no-umuim-coverage.
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  • Zalma’s Insurance Fraud Letter September 15, 2024

    Zalma’s Insurance Fraud Letter

    A ClaimSchool™ Publication © 2024 Barry Zalma & ClaimSchool, Inc.

    Read the full issue at https://www.linkedin.com/pulse/zalmas-insurance-fraud-letter-november-15-2024-barry-zalma-esq-cfe-cxkycVolume 28, Issue 21 – November 15, 2024

    “Honor, justice, and humanity, forbid us tamely to surrender that freedom which we received from our gallant ancestors, and which our innocent posterity have a right to receive from us. We cannot endure the infamy and guilt of resigning succeeding generations to that wretchedness which inevitably awaits them if we basely entail hereditary bondage on them.”

    Thomas Jefferson

    Insurance Fraud Requires Doctor to Lose his License

    Sexual Misconduct, Fraud, Bribery & Unnecessary Surgery Revokes License

    Louis Quartararo appealed from an August 22, 2022 final agency decision of the State Board of Medical Examiners (Board), revoking his license to practice medicine and surgery in New Jersey. The Superior Court of New Jersey, in In The Matter Of The Suspension Or Revocation Of The License Of Louis Quartararo, M.D. License No. 25MA07137700 To Practice Medicine And Surgery In The State Of New Jersey, No. A-0425-22, Superior Court of New Jersey, Appellate Division (October 31, 2024) affirmed the revocation.

    The Board charged Dr. Quartararo with engaging in sexual contact with patients; negligent acts by performing surgeries with co-surgeons who lacked the requisite privileges; and acts of fraud, deception and misrepresentation by miscoding procedures on patient operative reports and listing procedures in the reports he had not performed for the purpose of ensuring insurance coverage.

    FACTS

    Quartararo was a physician and Board-certified orthopedic surgeon licensed to practice medicine in New Jersey.

    Approximately one week before K.D. was scheduled to meet with Board investigators, Quartararo gave K.D. $20,916, which K.D. told an investigator was “for school.” Later, Quartararo’s attorney offered her more money to retract the statement she had made to the Board about her relationship with Quartararo.

    THE OAL HEARING

    At a formal hearing, the Board’s expert, Dr. Ashraf addressed Quartararo’s treatment of patient Y.O. revealed that the surgical procedures Quartararo performed were not medically necessary. In reviewing the description of Quartararo’s procedure on Y.O.’s spine, Dr. Ashraf concluded that Quartararo’s surgery on Y.O.’s completely normal spine “is gross negligence.”

    Regarding the fraud claims alleging that Quartararo had failed to properly code surgical procedures that he performed on E.S., D.C., Y.O., L.V., D.E., and V.C., Dr. Ashraf testified that the “whole function” of the “operations” section on the first page of the operative report was to list the procedures that were performed during the operation and he testified that, despite “laminotomy” appearing on the first page of V.C.’s and D.C.’s reports, their post-surgery MRIs revealed that laminotomies had not been performed.

    THE ALJ’S DECISION

    The Administrative Law Judge (ALJ) issued a comprehensive seventy-nine-page decision and concluded that Quartararo had “engaged in gross malpractice, professional misconduct, failure to comply with regulations administered by the Board, and failure to be of good moral character.”

    On August 22, 2022, the Board filed its final decision, revoking Quartararo’s license for a minimum of seven years from the date of voluntary surrender, April 5, 2019. The Board concluded that Quartararo’s “misconduct warrants a serious penalty in excess of that recommended by [the ALJ]” and that he “flagrantly ignored, and in fact shattered professional norms when he engaged in sexual misconduct with patients Y.R. and K.D.” The Board found Quartararo’s conduct was “so egregious that the only appropriate discipline is a license revocation.”

    The Board also imposed an aggregate monetary sanction of $343,909.75, comprised of a civil penalty of $90,000, $61,684.75 in costs, and $192,225 in attorney’s fees.

    Quartararo Argued

    The Board determined that revocation was warranted because he preyed on two vulnerable patients employed intimidation and coercion tactics to dissuade at least one of his victims-K.D.- from testifying about the true nature of their relation and resorted to making threats resulting in the issuance of a temporary restraining order against him.

    Quartararo admitted he had not performed laminotomies and that he had used the laminotomy code to ensure that he would be paid by insurance carriers. He did so rather than correctly coding the procedures he actually performed because of the risk he would otherwise not be paid.

    ZIFL OPINION

    Quartararo admitted before the ALJ that he committed fraud by billing insurers for laminotomies that he did not perform. As such he admitted to committing a federal as well as a New Jersey felony that should be presented to the US Attorney and the local District Attorney for prosecution. He lost his license because he took advantage sexually of vulnerable patients, committed gross acts of malpractice and profited from knowing insurance fraud. The people of New Jersey are now safe from his criminal and unprofessional conduct for a few more years, and in my opinion he should be prosecuted and sentenced to prison for the fraud.

    Read the full issue at https://www.linkedin.com/pulse/zalmas-insurance-fraud-letter-november-15-2024-barry-zalma-esq-cfe-cxkyc

    IT PAYS INSURER DEFENDANTS TO INVESTIGATE INJURY CLAIMS

    In Chris Kallco v. Melissa Lynn Pugh, Chris Kallco, and Precise Mri Of Michigan, LLC v. Citizens Insurance Company Of The Midwest and Melissa Lynn Pugh, No. 368156, Court of Appeals of Michigan (October 30, 2024) affirmed the trial court’s decision.

    Plaintiff appealed from two orders granting summary disposition in favor of defendants even though he failed to respond to either motion.

    FACTUAL BACKGROUND

    This case arises out of a motor vehicle accident that occurred on March 9, 2020 involving plaintiff and Pugh. Plaintiff alleges that he sustained injuries from the accident. A year after the accident, plaintiff brought a negligence claim against Pugh, alleging that, because of Pugh’s negligence, plaintiff sustained “severe permanent and progressive personal injuries and serious impairment of a body function, including but not necessarily limited to: Head, Neck, Back, Shoulders ….” Plaintiff also brought a claim against Citizens for PIP benefits, including medical expenses, work loss, and replacement services.

    Pugh and Citizens moved for summary disposition arguing that plaintiff could not meet his burden of showing that he sustained a threshold injury under the no-fault act and, therefore, he could not maintain his negligence claim against her. Pugh submitted the deposition testimony of the plaintiff and the report of an independent medical examination (IME) conducted by Dr. James Bragman on December 27, 2021. Dr. Bragman further observed that plaintiff had “near full range of motion” in his neck and that he was “eminently capable” of standing and touching his toes despite his refusal to do so. Dr. Bragman noted that plaintiff had “very little” medical treatment documented in his records and that he had been undergoing physical therapy for six months with no medical basis for doing so. An investigator’s report includes pictures of plaintiff walking, riding a child’s bicycle, squatting, bending over, lifting a bicycle out of a minivan unassisted, playing with a dog, driving a car, and twisting his neck.

    Citizens’ motion argued that plaintiff made material misrepresentations to Citizens regarding the extent of his injuries, which rendered him ineligible for benefits.

    The trial court found that, based upon the evidence presented, plaintiff failed to establish that he sustained a serious impairment of body function and therefore summary disposition in favor of Pugh was appropriate.

    THRESHOLD INJURY

    Plaintiff argued that the trial court erred by granting summary disposition in favor of Pugh.

    Under the no fault statute, the threshold question of whether the person has suffered a serious impairment of body function should be determined by the court as a matter of law as long as there is no factual dispute regarding the nature and extent of the person’s injuries that is material to determining whether the threshold standards are met.

    Plaintiff was obligated to respond to Pugh’s motion in order to meet his burden of demonstrating that a fact question existed as to whether he suffered a serious impairment of body function.

    The parts of plaintiff’s deposition identified by Pugh do not establish a genuine issue of material fact as to whether he suffered a serious impairment of body function. The relevant portions of plaintiff’s deposition testimony fail to rebut the evidence and instead set forth, at best, mere subjective complaints of pain.

    FRAUDULENT INSURANCE ACT

    The fraud statute finds that a person who presents or causes or to be presented an oral or written statement knowing that the statement contains false information concerning a fact or thing material to the claim commits a fraudulent insurance act under that is subject to the penalties imposed under the statute. A claim that contains or is supported by a fraudulent insurance act as described in this subsection is ineligible for payment of PIP benefits.

    An individual commits a “fraudulent insurance act” when: (1) the person presents or causes to be presented an oral or written statement, (2) the statement is part of or in support of a claim for no-fault benefits, and (3) the claim for benefits was submitted to the MAIPF. Further, (4) the person must have known that the statement contained false information, and (5) the statement concerned a fact or thing material to the claim.

    ZIFL OPINION

    The evidence presented by the defendants were damning since they established the injuries claimed were false. Plaintiff failed to respond to the motions to his detriment and sought reconsideration without any admissible evidence that he was truly injured. The defendants established that the Plaintiff committed fraud and he is lucky that this was a civil finding not a criminal proceeding that, in my opinion, should be presented by the prosecutor.

    More McClenny Moseley & Associates Issues

    This is ZIFL’s thirty seventh 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 conduct to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana.

    Health Insurance Fraud Convictions
    Pharmacist and Brother Convicted of $15M Medicare, Medicaid, and Private Insurer Fraud Scheme

    Raad Kouza, a pharmacist in Wayne County, Michigan, and his brother, Ramis Kouza, of Oakland County, Michigan, billed Medicare, Medicaid, and Blue Cross Blue Shield of Michigan for prescription medications that they did not dispense at pharmacies they owned or operated in Michigan. A federal jury convicted the pharmacy owner and his brother November 8, 2024 for conspiracy to commit health care fraud and wire fraud.

    Read the full article and the full issue of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/11/ZIFL-11-15-2024-1.pdf

    Indicators of Bad Faith Set Up

    Some of the more common red flags of a bad faith set-up include the following:

    The claimant makes a policy limits settlement demand quickly after an accident, thereby depriving the insurer of the ability to conduct a full investigation.
    Quick demands that are combined with a limited amount of time to accept, again, in the hopes that records cannot be obtained and the investigation cannot be completed within that limited time period, and the settlement will be refused.
    The claimant makes a settlement offer with one or more unusual acceptance conditions.
    The involvement of the claimant’s counsel pre-dates certain medical or psychiatric care (e.g., testing and treatment for alleged mild traumatic brain injury)

    Read the full article and the full issue of ZIFL at http://https//zalma.com/blog/wp-content/uploads/2024/11/ZIFL-11-15-2024.pdf

    Convictions of Other Than Health Insurance Fraud
    Star in Reality TV Series Pleads Guilty Crop Insurance Fraud

    Steve A. McBee, 52, waived his right to a grand jury and pleaded guilty to a federal information that charges him with one count of federal crop insurance fraud. McBee, a Missouri farmer who appears in a reality TV show about his family’s farming operation pleaded guilty this week to a multi-million dollar fraud scheme involving federal crop insurance benefits.

    Read the full article and the full issue of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/11/ZIFL-11-15-2024-1.pdf

    Chutzpah – STOLI Fraudster Claims Hardship
    Felon Seeks Release from Home Confinement in Luxury Apartment in New York City

    Insurance Fraud is a serious crime, especially when it takes advantage of the elderly to defraud insurers in a Stranger Originated Life Insurance (STOLI) scheme. In United States Of America v. Michael Binday, No. 12 CR 152 (CM), United States District Court, S.D. New York (November 4, 2024) the defendant continued to use the wealth he gained from his fraud to impose on the courts of the United States with frivolous and unfounded motions.

    Read the full article and the full issue of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/11/ZIFL-11-15-2024-1.pdf

    Barry Zalma, Esq., CFE

    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.
    Zalma’s Insurance Fraud Letter September 15, 2024 Zalma’s Insurance Fraud Letter A ClaimSchool™ Publication © 2024 Barry Zalma & ClaimSchool, Inc. Read the full issue at https://www.linkedin.com/pulse/zalmas-insurance-fraud-letter-november-15-2024-barry-zalma-esq-cfe-cxkycVolume 28, Issue 21 – November 15, 2024 “Honor, justice, and humanity, forbid us tamely to surrender that freedom which we received from our gallant ancestors, and which our innocent posterity have a right to receive from us. We cannot endure the infamy and guilt of resigning succeeding generations to that wretchedness which inevitably awaits them if we basely entail hereditary bondage on them.” Thomas Jefferson Insurance Fraud Requires Doctor to Lose his License Sexual Misconduct, Fraud, Bribery & Unnecessary Surgery Revokes License Louis Quartararo appealed from an August 22, 2022 final agency decision of the State Board of Medical Examiners (Board), revoking his license to practice medicine and surgery in New Jersey. The Superior Court of New Jersey, in In The Matter Of The Suspension Or Revocation Of The License Of Louis Quartararo, M.D. License No. 25MA07137700 To Practice Medicine And Surgery In The State Of New Jersey, No. A-0425-22, Superior Court of New Jersey, Appellate Division (October 31, 2024) affirmed the revocation. The Board charged Dr. Quartararo with engaging in sexual contact with patients; negligent acts by performing surgeries with co-surgeons who lacked the requisite privileges; and acts of fraud, deception and misrepresentation by miscoding procedures on patient operative reports and listing procedures in the reports he had not performed for the purpose of ensuring insurance coverage. FACTS Quartararo was a physician and Board-certified orthopedic surgeon licensed to practice medicine in New Jersey. Approximately one week before K.D. was scheduled to meet with Board investigators, Quartararo gave K.D. $20,916, which K.D. told an investigator was “for school.” Later, Quartararo’s attorney offered her more money to retract the statement she had made to the Board about her relationship with Quartararo. THE OAL HEARING At a formal hearing, the Board’s expert, Dr. Ashraf addressed Quartararo’s treatment of patient Y.O. revealed that the surgical procedures Quartararo performed were not medically necessary. In reviewing the description of Quartararo’s procedure on Y.O.’s spine, Dr. Ashraf concluded that Quartararo’s surgery on Y.O.’s completely normal spine “is gross negligence.” Regarding the fraud claims alleging that Quartararo had failed to properly code surgical procedures that he performed on E.S., D.C., Y.O., L.V., D.E., and V.C., Dr. Ashraf testified that the “whole function” of the “operations” section on the first page of the operative report was to list the procedures that were performed during the operation and he testified that, despite “laminotomy” appearing on the first page of V.C.’s and D.C.’s reports, their post-surgery MRIs revealed that laminotomies had not been performed. THE ALJ’S DECISION The Administrative Law Judge (ALJ) issued a comprehensive seventy-nine-page decision and concluded that Quartararo had “engaged in gross malpractice, professional misconduct, failure to comply with regulations administered by the Board, and failure to be of good moral character.” On August 22, 2022, the Board filed its final decision, revoking Quartararo’s license for a minimum of seven years from the date of voluntary surrender, April 5, 2019. The Board concluded that Quartararo’s “misconduct warrants a serious penalty in excess of that recommended by [the ALJ]” and that he “flagrantly ignored, and in fact shattered professional norms when he engaged in sexual misconduct with patients Y.R. and K.D.” The Board found Quartararo’s conduct was “so egregious that the only appropriate discipline is a license revocation.” The Board also imposed an aggregate monetary sanction of $343,909.75, comprised of a civil penalty of $90,000, $61,684.75 in costs, and $192,225 in attorney’s fees. Quartararo Argued The Board determined that revocation was warranted because he preyed on two vulnerable patients employed intimidation and coercion tactics to dissuade at least one of his victims-K.D.- from testifying about the true nature of their relation and resorted to making threats resulting in the issuance of a temporary restraining order against him. Quartararo admitted he had not performed laminotomies and that he had used the laminotomy code to ensure that he would be paid by insurance carriers. He did so rather than correctly coding the procedures he actually performed because of the risk he would otherwise not be paid. ZIFL OPINION Quartararo admitted before the ALJ that he committed fraud by billing insurers for laminotomies that he did not perform. As such he admitted to committing a federal as well as a New Jersey felony that should be presented to the US Attorney and the local District Attorney for prosecution. He lost his license because he took advantage sexually of vulnerable patients, committed gross acts of malpractice and profited from knowing insurance fraud. The people of New Jersey are now safe from his criminal and unprofessional conduct for a few more years, and in my opinion he should be prosecuted and sentenced to prison for the fraud. Read the full issue at https://www.linkedin.com/pulse/zalmas-insurance-fraud-letter-november-15-2024-barry-zalma-esq-cfe-cxkyc IT PAYS INSURER DEFENDANTS TO INVESTIGATE INJURY CLAIMS In Chris Kallco v. Melissa Lynn Pugh, Chris Kallco, and Precise Mri Of Michigan, LLC v. Citizens Insurance Company Of The Midwest and Melissa Lynn Pugh, No. 368156, Court of Appeals of Michigan (October 30, 2024) affirmed the trial court’s decision. Plaintiff appealed from two orders granting summary disposition in favor of defendants even though he failed to respond to either motion. FACTUAL BACKGROUND This case arises out of a motor vehicle accident that occurred on March 9, 2020 involving plaintiff and Pugh. Plaintiff alleges that he sustained injuries from the accident. A year after the accident, plaintiff brought a negligence claim against Pugh, alleging that, because of Pugh’s negligence, plaintiff sustained “severe permanent and progressive personal injuries and serious impairment of a body function, including but not necessarily limited to: Head, Neck, Back, Shoulders ….” Plaintiff also brought a claim against Citizens for PIP benefits, including medical expenses, work loss, and replacement services. Pugh and Citizens moved for summary disposition arguing that plaintiff could not meet his burden of showing that he sustained a threshold injury under the no-fault act and, therefore, he could not maintain his negligence claim against her. Pugh submitted the deposition testimony of the plaintiff and the report of an independent medical examination (IME) conducted by Dr. James Bragman on December 27, 2021. Dr. Bragman further observed that plaintiff had “near full range of motion” in his neck and that he was “eminently capable” of standing and touching his toes despite his refusal to do so. Dr. Bragman noted that plaintiff had “very little” medical treatment documented in his records and that he had been undergoing physical therapy for six months with no medical basis for doing so. An investigator’s report includes pictures of plaintiff walking, riding a child’s bicycle, squatting, bending over, lifting a bicycle out of a minivan unassisted, playing with a dog, driving a car, and twisting his neck. Citizens’ motion argued that plaintiff made material misrepresentations to Citizens regarding the extent of his injuries, which rendered him ineligible for benefits. The trial court found that, based upon the evidence presented, plaintiff failed to establish that he sustained a serious impairment of body function and therefore summary disposition in favor of Pugh was appropriate. THRESHOLD INJURY Plaintiff argued that the trial court erred by granting summary disposition in favor of Pugh. Under the no fault statute, the threshold question of whether the person has suffered a serious impairment of body function should be determined by the court as a matter of law as long as there is no factual dispute regarding the nature and extent of the person’s injuries that is material to determining whether the threshold standards are met. Plaintiff was obligated to respond to Pugh’s motion in order to meet his burden of demonstrating that a fact question existed as to whether he suffered a serious impairment of body function. The parts of plaintiff’s deposition identified by Pugh do not establish a genuine issue of material fact as to whether he suffered a serious impairment of body function. The relevant portions of plaintiff’s deposition testimony fail to rebut the evidence and instead set forth, at best, mere subjective complaints of pain. FRAUDULENT INSURANCE ACT The fraud statute finds that a person who presents or causes or to be presented an oral or written statement knowing that the statement contains false information concerning a fact or thing material to the claim commits a fraudulent insurance act under that is subject to the penalties imposed under the statute. A claim that contains or is supported by a fraudulent insurance act as described in this subsection is ineligible for payment of PIP benefits. An individual commits a “fraudulent insurance act” when: (1) the person presents or causes to be presented an oral or written statement, (2) the statement is part of or in support of a claim for no-fault benefits, and (3) the claim for benefits was submitted to the MAIPF. Further, (4) the person must have known that the statement contained false information, and (5) the statement concerned a fact or thing material to the claim. ZIFL OPINION The evidence presented by the defendants were damning since they established the injuries claimed were false. Plaintiff failed to respond to the motions to his detriment and sought reconsideration without any admissible evidence that he was truly injured. The defendants established that the Plaintiff committed fraud and he is lucky that this was a civil finding not a criminal proceeding that, in my opinion, should be presented by the prosecutor. More McClenny Moseley & Associates Issues This is ZIFL’s thirty seventh 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 conduct to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana. Health Insurance Fraud Convictions Pharmacist and Brother Convicted of $15M Medicare, Medicaid, and Private Insurer Fraud Scheme Raad Kouza, a pharmacist in Wayne County, Michigan, and his brother, Ramis Kouza, of Oakland County, Michigan, billed Medicare, Medicaid, and Blue Cross Blue Shield of Michigan for prescription medications that they did not dispense at pharmacies they owned or operated in Michigan. A federal jury convicted the pharmacy owner and his brother November 8, 2024 for conspiracy to commit health care fraud and wire fraud. Read the full article and the full issue of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/11/ZIFL-11-15-2024-1.pdf Indicators of Bad Faith Set Up Some of the more common red flags of a bad faith set-up include the following: The claimant makes a policy limits settlement demand quickly after an accident, thereby depriving the insurer of the ability to conduct a full investigation. Quick demands that are combined with a limited amount of time to accept, again, in the hopes that records cannot be obtained and the investigation cannot be completed within that limited time period, and the settlement will be refused. The claimant makes a settlement offer with one or more unusual acceptance conditions. The involvement of the claimant’s counsel pre-dates certain medical or psychiatric care (e.g., testing and treatment for alleged mild traumatic brain injury) Read the full article and the full issue of ZIFL at http://https//zalma.com/blog/wp-content/uploads/2024/11/ZIFL-11-15-2024.pdf Convictions of Other Than Health Insurance Fraud Star in Reality TV Series Pleads Guilty Crop Insurance Fraud Steve A. McBee, 52, waived his right to a grand jury and pleaded guilty to a federal information that charges him with one count of federal crop insurance fraud. McBee, a Missouri farmer who appears in a reality TV show about his family’s farming operation pleaded guilty this week to a multi-million dollar fraud scheme involving federal crop insurance benefits. Read the full article and the full issue of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/11/ZIFL-11-15-2024-1.pdf Chutzpah – STOLI Fraudster Claims Hardship Felon Seeks Release from Home Confinement in Luxury Apartment in New York City Insurance Fraud is a serious crime, especially when it takes advantage of the elderly to defraud insurers in a Stranger Originated Life Insurance (STOLI) scheme. In United States Of America v. Michael Binday, No. 12 CR 152 (CM), United States District Court, S.D. New York (November 4, 2024) the defendant continued to use the wealth he gained from his fraud to impose on the courts of the United States with frivolous and unfounded motions. Read the full article and the full issue of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/11/ZIFL-11-15-2024-1.pdf Barry Zalma, Esq., CFE 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.
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  • No Breach of Contract no Bad Faith

    Happy Veterans Day to My Fellow Veterans

    Some Claims Proper Some Not

    Read the full article at https://www.linkedin.com/pulse/happy-veterans-day-my-fellow-barry-zalma-esq-cfe-ovpec, shttps://www.linkedin.com/pulse/happy-veterans-day-my-fellow-barry-zalma-esq-cfe-ovpec and at https://zalma.com/blog plus more than 4900 posts.

    Post 4929

    Vepo Design Corporation and its officers (collectively, “Vepo”) appealed the district court’s grant of summary judgment on their breach of contract and bad faith claims against American Economy Insurance Company (“AEIC”). Vepo’s claims relate to AEIC’s denial of coverage following a fire in a laundromat, known as the “Central Laundromat,” which Vepo was developing.

    In Vepo Design Corporation, et al. v. American Economy Insurance Company, No. 23-55634, United States Court of Appeals, Ninth Circuit (November 4, 2024) the issues were resolved serially.

    DECISIONS

    Business Income

    The Ninth Circuit reversed the district court’s grant of summary judgment in favor of AEIC on Vepo’s business income claim, which concerns income Vepo contends it would have earned operating the Central Laundromat if the fire had not occurred. AEIC argued that Vepo’s claim for lost income was too speculative given that the Central Laundromat was still under construction and Vepo had not secured additional financing to own and operate it.

    Construing the facts in the light most favorable to Vepo as the non-moving party the Ninth Circuit concluded that there is sufficient evidence to create a genuine dispute of material fact and that Vepo’s claim for lost business income is not unduly speculative.

    There is evidence that Vepo was contemplating an arrangement under which it would own and operate the Central Laundromat for a period of time before selling it, and that Vepo later engaged in similar arrangements for other laundromats. Vepo, which was experienced in the laundromat industry, also demonstrated that it had a history of securing financing for its laundromat projects and that it intended to refinance the Central Laundromat once a certificate of occupancy was received. Although Vepo had not secured refinancing for the Central Laundromat as of the time of the fire, Vepo’s Principal Owner stated in her declaration and confirmed at her deposition that it was too early to do so in the project timeline. That Vepo had yet to refinance does not render its claim too speculative as a matter of law and its losses are for a jury to decide.

    Extra Expense

    The Ninth Circuit affirmed the district court’s grant of summary judgment in favor of AEIC for the extra expenses that Vepo allegedly incurred in storing laundry equipment in a warehouse owned by Vepo’s sister company following the fire. While the policy only required the expense to be incurred, not paid, there was insufficient evidence to create a triable issue over whether the expense was incurred at all. No payment changed hands between the two entities, and there is no accounting record showing that Vepo was liable for the storage amount. When the same person signed as representative of both entities, does not create a genuine dispute of material fact.

    Lost Profits

    The Ninth Circuit concluded that the district court properly granted summary judgment on Vepo’s claim for lost profits on the prospective sale of the laundromat. Even assuming that such a loss would be covered under the policy, the claim fails because the policy limited coverage to losses that occur within one year of the incident. Vepo’s plan called for it to own and operate the Central Laundromat for at least one year after opening, which would place any hypothetical sale more than a year after the pre-opening fire.

    Individual Personal Property Claims

    The Ninth Circuit affirmed summary judgment for AEIC on the claims by the individual plaintiffs for their own personal property that was allegedly lost in the fire. As the district court correctly found, Vepo did not identify what individual property was lost or its worth. The individual plaintiffs’ claims were too unsupported to create a triable issue.

    Bad Faith

    The Ninth Circuit partially reversed the district court’s grant of summary judgment on Vepo’s bad faith claim, to the extent of the single insurance claim it allowed to go forward-the business income claim.

    The district court may permit any further motions practice on the bad faith claim as it deems appropriate. However, it affirmed the district court’s grant of summary judgment on the bad faith claim insofar as that claim is premised on any of the other breach of contract claims to which AEIC is entitled to judgment as a matter of law.

    There is never a claim for breach of the implied duty of good faith and fair dealing if there was no improper denial of coverage under the policy.

    ZALMA OPINION

    The importance of this case is the reiteration of the law that there can never be a viable tort of bad faith if there is no improper denial of a claim by breach of the insurance contract. If the one cause of action remaining was breached in bad faith and there was no genuine dispute over coverage, that cause can be brought for bad faith damages. The other decisions of the Ninth Circuit were obvious and well reasoned.

    (c) 2024 Barry Zalma & ClaimSchool, Inc.

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    No Breach of Contract no Bad Faith Happy Veterans Day to My Fellow Veterans Some Claims Proper Some Not Read the full article at https://www.linkedin.com/pulse/happy-veterans-day-my-fellow-barry-zalma-esq-cfe-ovpec, shttps://www.linkedin.com/pulse/happy-veterans-day-my-fellow-barry-zalma-esq-cfe-ovpec and at https://zalma.com/blog plus more than 4900 posts. Post 4929 Vepo Design Corporation and its officers (collectively, “Vepo”) appealed the district court’s grant of summary judgment on their breach of contract and bad faith claims against American Economy Insurance Company (“AEIC”). Vepo’s claims relate to AEIC’s denial of coverage following a fire in a laundromat, known as the “Central Laundromat,” which Vepo was developing. In Vepo Design Corporation, et al. v. American Economy Insurance Company, No. 23-55634, United States Court of Appeals, Ninth Circuit (November 4, 2024) the issues were resolved serially. DECISIONS Business Income The Ninth Circuit reversed the district court’s grant of summary judgment in favor of AEIC on Vepo’s business income claim, which concerns income Vepo contends it would have earned operating the Central Laundromat if the fire had not occurred. AEIC argued that Vepo’s claim for lost income was too speculative given that the Central Laundromat was still under construction and Vepo had not secured additional financing to own and operate it. Construing the facts in the light most favorable to Vepo as the non-moving party the Ninth Circuit concluded that there is sufficient evidence to create a genuine dispute of material fact and that Vepo’s claim for lost business income is not unduly speculative. There is evidence that Vepo was contemplating an arrangement under which it would own and operate the Central Laundromat for a period of time before selling it, and that Vepo later engaged in similar arrangements for other laundromats. Vepo, which was experienced in the laundromat industry, also demonstrated that it had a history of securing financing for its laundromat projects and that it intended to refinance the Central Laundromat once a certificate of occupancy was received. Although Vepo had not secured refinancing for the Central Laundromat as of the time of the fire, Vepo’s Principal Owner stated in her declaration and confirmed at her deposition that it was too early to do so in the project timeline. That Vepo had yet to refinance does not render its claim too speculative as a matter of law and its losses are for a jury to decide. Extra Expense The Ninth Circuit affirmed the district court’s grant of summary judgment in favor of AEIC for the extra expenses that Vepo allegedly incurred in storing laundry equipment in a warehouse owned by Vepo’s sister company following the fire. While the policy only required the expense to be incurred, not paid, there was insufficient evidence to create a triable issue over whether the expense was incurred at all. No payment changed hands between the two entities, and there is no accounting record showing that Vepo was liable for the storage amount. When the same person signed as representative of both entities, does not create a genuine dispute of material fact. Lost Profits The Ninth Circuit concluded that the district court properly granted summary judgment on Vepo’s claim for lost profits on the prospective sale of the laundromat. Even assuming that such a loss would be covered under the policy, the claim fails because the policy limited coverage to losses that occur within one year of the incident. Vepo’s plan called for it to own and operate the Central Laundromat for at least one year after opening, which would place any hypothetical sale more than a year after the pre-opening fire. Individual Personal Property Claims The Ninth Circuit affirmed summary judgment for AEIC on the claims by the individual plaintiffs for their own personal property that was allegedly lost in the fire. As the district court correctly found, Vepo did not identify what individual property was lost or its worth. The individual plaintiffs’ claims were too unsupported to create a triable issue. Bad Faith The Ninth Circuit partially reversed the district court’s grant of summary judgment on Vepo’s bad faith claim, to the extent of the single insurance claim it allowed to go forward-the business income claim. The district court may permit any further motions practice on the bad faith claim as it deems appropriate. However, it affirmed the district court’s grant of summary judgment on the bad faith claim insofar as that claim is premised on any of the other breach of contract claims to which AEIC is entitled to judgment as a matter of law. There is never a claim for breach of the implied duty of good faith and fair dealing if there was no improper denial of coverage under the policy. ZALMA OPINION The importance of this case is the reiteration of the law that there can never be a viable tort of bad faith if there is no improper denial of a claim by breach of the insurance contract. If the one cause of action remaining was breached in bad faith and there was no genuine dispute over coverage, that cause can be brought for bad faith damages. The other decisions of the Ninth Circuit were obvious and well reasoned. (c) 2024 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 Newsbreak.com https://www.newsbreak.com/@c/1653419?s=01; 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 Insurance Claims Library – https://lnkd.in/gwEYk
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  • Fraudulent Claims of Injury Defeated

    Respond to Motions for Summary Adjudication or Always Lose
    Posted on November 8, 2024 by Barry Zalma

    Post 4928

    Read the full article at https://www.linkedin.com/pulse/fraudulent-claims-injury-defeated-barry-zalma-esq-cfe-kitgc, See the full video at and at and at https://zalma.com/blog

    IT PAYS DEFENDANTS TO INVESTIGATE INJURY CLAIMS

    Plaintiff appealed from two orders granting summary disposition in favor of defendants even though he failed to respond to either motion.

    In Chris Kallco v. Melissa Lynn Pugh, Chris Kallco, and Precise Mri Of Michigan, LLC v. Citizens Insurance Company Of The Midwest and Melissa Lynn Pugh, No. 368156, Court of Appeals of Michigan (October 30, 2024) affirmed the trial court’s decision.

    FACTUAL BACKGROUND

    This case arises out of a motor vehicle accident that occurred on March 9, 2020 involving plaintiff and Pugh. Plaintiff alleges that he sustained injuries from the accident. A year after the accident, plaintiff brought a negligence claim against Pugh, alleging that, because of Pugh’s negligence, plaintiff sustained “severe permanent and progressive personal injuries and serious impairment of a body function, including but not necessarily limited to: Head, Neck, Back, Shoulders ….” Plaintiff also brought a claim against Citizens for PIP benefits, including medical expenses, work loss, and replacement services.

    Pugh and Citizens moved for summary disposition arguing that plaintiff could not meet his burden of showing that he sustained a threshold injury under the no-fault act and, therefore, he could not maintain his negligence claim against her. Pugh submitted the deposition testimony of the plaintiff and the report of an independent medical examination (IME) conducted by Dr. James Bragman on December 27, 2021. Dr. Bragman further observed that plaintiff had “near full range of motion” in his neck and that he was “eminently capable” of standing and touching his toes despite his refusal to do so. Dr. Bragman noted that plaintiff had “very little” medical treatment documented in his records and that he had been undergoing physical therapy for six months with no medical basis for doing so. An investigator’s report includes pictures of plaintiff walking, riding a child’s bicycle, squatting, bending over, lifting a bicycle out of a minivan unassisted, playing with a dog, driving a car, and twisting his neck.

    Citizens’ motion argued that plaintiff made material misrepresentations to Citizens regarding the extent of his injuries, which rendered him ineligible for benefits.

    The trial court found that, based upon the evidence presented, plaintiff failed to establish that he sustained a serious impairment of body function and therefore summary disposition in favor of Pugh was appropriate.

    THRESHOLD INJURY

    Plaintiff argued that the trial court erred by granting summary disposition in favor of Pugh.

    Under the no fault statute the threshold question of whether the person has suffered a serious impairment of body function should be determined by the court as a matter of law as long as there is no factual dispute regarding the nature and extent of the person’s injuries that is material to determining whether the threshold standards are met.

    Plaintiff was obligated to respond to Pugh’s motion in order to meet his burden of demonstrating that a fact question existed as to whether he suffered a serious impairment of body function.

    The parts of plaintiff’s deposition identified by Pugh do not establish a genuine issue of material fact as to whether he suffered a serious impairment of body function. The relevant portions of plaintiff’s deposition testimony fail to rebut the evidence and instead set forth, at best, mere subjective complaints of pain.

    FRAUDULENT INSURANCE ACT

    The fraud statute finds that a person who presents or causes to be presented an oral or written statement knowing that the statement contains false information concerning a fact or thing material to the claim commits a fraudulent insurance act under that is subject to the penalties imposed under the statute. A claim that contains or is supported by a fraudulent insurance act as described in this subsection is ineligible for payment of PIP benefits.

    An individual commits a “fraudulent insurance act” when: (1) the person presents or causes to be presented an oral or written statement, (2) the statement is part of or in support of a claim for no-fault benefits, and (3) the claim for benefits was submitted to the MAIPF. Further, (4) the person must have known that the statement contained false information, and (5) the statement concerned a fact or thing material to the claim.

    ZALMA OPINION

    The evidence presented by the defendants were damning since they established the injuries claimed were false. Plaintiff failed to respond to the motions to his detriment and sought reconsideration without any admissible evidence that he was truly injured. The defendants established that the Plaintiff committed fraud and he is lucky that this was a civil finding not a criminal proceeding that, in my opinion, should be presented by the prosecutor.

    (c) 2024 Barry Zalma & ClaimSchool, Inc.

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    Fraudulent Claims of Injury Defeated Respond to Motions for Summary Adjudication or Always Lose Posted on November 8, 2024 by Barry Zalma Post 4928 Read the full article at https://www.linkedin.com/pulse/fraudulent-claims-injury-defeated-barry-zalma-esq-cfe-kitgc, See the full video at and at and at https://zalma.com/blog IT PAYS DEFENDANTS TO INVESTIGATE INJURY CLAIMS Plaintiff appealed from two orders granting summary disposition in favor of defendants even though he failed to respond to either motion. In Chris Kallco v. Melissa Lynn Pugh, Chris Kallco, and Precise Mri Of Michigan, LLC v. Citizens Insurance Company Of The Midwest and Melissa Lynn Pugh, No. 368156, Court of Appeals of Michigan (October 30, 2024) affirmed the trial court’s decision. FACTUAL BACKGROUND This case arises out of a motor vehicle accident that occurred on March 9, 2020 involving plaintiff and Pugh. Plaintiff alleges that he sustained injuries from the accident. A year after the accident, plaintiff brought a negligence claim against Pugh, alleging that, because of Pugh’s negligence, plaintiff sustained “severe permanent and progressive personal injuries and serious impairment of a body function, including but not necessarily limited to: Head, Neck, Back, Shoulders ….” Plaintiff also brought a claim against Citizens for PIP benefits, including medical expenses, work loss, and replacement services. Pugh and Citizens moved for summary disposition arguing that plaintiff could not meet his burden of showing that he sustained a threshold injury under the no-fault act and, therefore, he could not maintain his negligence claim against her. Pugh submitted the deposition testimony of the plaintiff and the report of an independent medical examination (IME) conducted by Dr. James Bragman on December 27, 2021. Dr. Bragman further observed that plaintiff had “near full range of motion” in his neck and that he was “eminently capable” of standing and touching his toes despite his refusal to do so. Dr. Bragman noted that plaintiff had “very little” medical treatment documented in his records and that he had been undergoing physical therapy for six months with no medical basis for doing so. An investigator’s report includes pictures of plaintiff walking, riding a child’s bicycle, squatting, bending over, lifting a bicycle out of a minivan unassisted, playing with a dog, driving a car, and twisting his neck. Citizens’ motion argued that plaintiff made material misrepresentations to Citizens regarding the extent of his injuries, which rendered him ineligible for benefits. The trial court found that, based upon the evidence presented, plaintiff failed to establish that he sustained a serious impairment of body function and therefore summary disposition in favor of Pugh was appropriate. THRESHOLD INJURY Plaintiff argued that the trial court erred by granting summary disposition in favor of Pugh. Under the no fault statute the threshold question of whether the person has suffered a serious impairment of body function should be determined by the court as a matter of law as long as there is no factual dispute regarding the nature and extent of the person’s injuries that is material to determining whether the threshold standards are met. Plaintiff was obligated to respond to Pugh’s motion in order to meet his burden of demonstrating that a fact question existed as to whether he suffered a serious impairment of body function. The parts of plaintiff’s deposition identified by Pugh do not establish a genuine issue of material fact as to whether he suffered a serious impairment of body function. The relevant portions of plaintiff’s deposition testimony fail to rebut the evidence and instead set forth, at best, mere subjective complaints of pain. FRAUDULENT INSURANCE ACT The fraud statute finds that a person who presents or causes to be presented an oral or written statement knowing that the statement contains false information concerning a fact or thing material to the claim commits a fraudulent insurance act under that is subject to the penalties imposed under the statute. A claim that contains or is supported by a fraudulent insurance act as described in this subsection is ineligible for payment of PIP benefits. An individual commits a “fraudulent insurance act” when: (1) the person presents or causes to be presented an oral or written statement, (2) the statement is part of or in support of a claim for no-fault benefits, and (3) the claim for benefits was submitted to the MAIPF. Further, (4) the person must have known that the statement contained false information, and (5) the statement concerned a fact or thing material to the claim. ZALMA OPINION The evidence presented by the defendants were damning since they established the injuries claimed were false. Plaintiff failed to respond to the motions to his detriment and sought reconsideration without any admissible evidence that he was truly injured. The defendants established that the Plaintiff committed fraud and he is lucky that this was a civil finding not a criminal proceeding that, in my opinion, should be presented by the prosecutor. (c) 2024 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 Newsbreak.com https://www.newsbreak.com/@c/1653419?s=01; 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 Insurance Claims Library – https://lnkd.in/gwEYk
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  • Permanent Punishment for Conviction for One Ounce of Cocaine Improper

    Government Overreach and Abuse Reversed

    Post 4927

    Read the full article at https://www.linkedin.com/pulse/permanent-punishment-conviction-one-ounce-cocaine-zalma-esq-cfe-geq1c, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts.

    After Recovery From Cocaine Abuse Dr. Regained License to Practice CMS Refused to Allow Dr. White to Bill Medicare for Services

    Dr. Stephen White challenged two unfavorable decisions made by the Secretary for the United States Department of Health and Human Services (the “Secretary”) that denied and revoked his Medicare enrollment. The decisions, rendered by the Appellate Division of the Departmental Appeals Board (“Board”), were based on Dr. White’s 2010 guilty plea and deferred prosecution for possession of less than 1 gram of cocaine, which occurred in Texas in 2007.

    In Stephen White, M.D. v. Xavier Becerra, Secretary for the United States Department of Health and Human Services, No. 2:19-CV-00037-SAB, United States District Court, E.D. Washington (October 28, 2024) the USDC applied entered a judgment reversing the decision of the Secretary [42 U.S.C. § 405(g).]

    SUMMARY JUDGMENT

    Summary judgment is appropriate if the movant shows that there is no genuine dispute as to any material fact.

    BACKGROUND

    Dr. White is an orthopedic surgeon. In 2006 and 2007, he was arrested and charged with possession of cocaine in Texas. He was able to rehab and become clean of his problem with the drug. The Texas Medical Board revoked his license, but then monitored his recovery and compliance and allowed him to practice again.

    Dr. White had no violations for nine years following his arrest. He is currently practicing medicine in Washington state and is an enrolled Medicare supplier.

    The Administrative Law Judge (ALJ) sustained the denial, finding that CMS had a legitimate basis because Dr. White was convicted of a felony offense. The Board affirmed the ALJ’s decision and Dr. White appealed that decision to the USDC.

    OVERVIEW OF MEDICARE PROGRAM

    The Medicare program provides health insurance benefits to people sixty-five years old or older and to eligible disabled persons. Suppliers, such as Dr. White, must be enrolled in the Medicare program and be granted billing privileges to be eligible to receive payment for care and services rendered to a Medicare-eligible beneficiary.

    DENIALS

    CMS may deny a supplier’s enrollment for any reason stated in federal statutes that allow that CMS may deny a provider’s or supplier’s enrollment in the Medicare program for the some of the following reasons: Felonies such as insurance fraud and similar crimes.

    REVOCATIONS

    The ALJ found CMS had a legitimate basis because White was convicted of a felony offense that CMS determined to be detrimental to the bests interest of the Medicare program and its beneficiaries.

    Dr. White’s presented equitable arguments to the ALJ that

    1 he self-reported and was not practicing;
    2 using his self-report to deny would encourage other physicians to not self-report,
    3 he has fully complied with the terms of the modified license, and
    eventually he was allowed to practice medicine without limitations.

    The Board affirmed the ALJ’s decision, upholding CMS’ denial of Dr. White’s Medicare enrollment and rejected Dr. White’s argument that the timing of the revocation action by CMS was clearly retaliatory and intended to apply pressure on Dr. White for additional monetary penalties.

    ANALYSIS

    The USDC found CMS’ decisions to deny Dr. White enrollment in Medicare and revoke his privileges, and the subsequent Board’s affirmations were arbitrary and capricious and not supported substantial evidence.

    CMS did not have a legitimate reason to deny enrollment or revoke because the record does not support CMS’ assertions that Dr. White’s 2010 conviction for simple possession of a small amount of cocaine was detrimental to the best interest of the Medicare program and its beneficiaries. The USDC understood the deference it owed to administrative agencies as they adjudicate numerous complex cases before them. Yet, a court may not simply act as a rubber stamp for agency decisions.

    Because CMS failed to provide a reasonable basis for denying Dr. White his enrollment in Medicare or revoking his Medicare privileges, the decision of the Secretary is reversed.

    ZALMA OPINION

    A doctor should never get involved or addicted to illegal substances like Cocaine. The Fact that a doctor self reports his involvement with the drug, was rehabilitated, clean for nine years, and practices medicine legally, does not pose a danger to Medicare as do those doctors who are arrested every year for fraud. The decision of Becerra, the ALJ and the Board was clearly retaliatory and abusive and the USDC had no choice but to reverse the Board and let the doctor continue to practice medicine and charge Medicare for his services. Overreach by the administrative agency was stopped by the court.

    (c) 2024 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.

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    Permanent Punishment for Conviction for One Ounce of Cocaine Improper Government Overreach and Abuse Reversed Post 4927 Read the full article at https://www.linkedin.com/pulse/permanent-punishment-conviction-one-ounce-cocaine-zalma-esq-cfe-geq1c, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts. After Recovery From Cocaine Abuse Dr. Regained License to Practice CMS Refused to Allow Dr. White to Bill Medicare for Services Dr. Stephen White challenged two unfavorable decisions made by the Secretary for the United States Department of Health and Human Services (the “Secretary”) that denied and revoked his Medicare enrollment. The decisions, rendered by the Appellate Division of the Departmental Appeals Board (“Board”), were based on Dr. White’s 2010 guilty plea and deferred prosecution for possession of less than 1 gram of cocaine, which occurred in Texas in 2007. In Stephen White, M.D. v. Xavier Becerra, Secretary for the United States Department of Health and Human Services, No. 2:19-CV-00037-SAB, United States District Court, E.D. Washington (October 28, 2024) the USDC applied entered a judgment reversing the decision of the Secretary [42 U.S.C. § 405(g).] SUMMARY JUDGMENT Summary judgment is appropriate if the movant shows that there is no genuine dispute as to any material fact. BACKGROUND Dr. White is an orthopedic surgeon. In 2006 and 2007, he was arrested and charged with possession of cocaine in Texas. He was able to rehab and become clean of his problem with the drug. The Texas Medical Board revoked his license, but then monitored his recovery and compliance and allowed him to practice again. Dr. White had no violations for nine years following his arrest. He is currently practicing medicine in Washington state and is an enrolled Medicare supplier. The Administrative Law Judge (ALJ) sustained the denial, finding that CMS had a legitimate basis because Dr. White was convicted of a felony offense. The Board affirmed the ALJ’s decision and Dr. White appealed that decision to the USDC. OVERVIEW OF MEDICARE PROGRAM The Medicare program provides health insurance benefits to people sixty-five years old or older and to eligible disabled persons. Suppliers, such as Dr. White, must be enrolled in the Medicare program and be granted billing privileges to be eligible to receive payment for care and services rendered to a Medicare-eligible beneficiary. DENIALS CMS may deny a supplier’s enrollment for any reason stated in federal statutes that allow that CMS may deny a provider’s or supplier’s enrollment in the Medicare program for the some of the following reasons: Felonies such as insurance fraud and similar crimes. REVOCATIONS The ALJ found CMS had a legitimate basis because White was convicted of a felony offense that CMS determined to be detrimental to the bests interest of the Medicare program and its beneficiaries. Dr. White’s presented equitable arguments to the ALJ that 1 he self-reported and was not practicing; 2 using his self-report to deny would encourage other physicians to not self-report, 3 he has fully complied with the terms of the modified license, and eventually he was allowed to practice medicine without limitations. The Board affirmed the ALJ’s decision, upholding CMS’ denial of Dr. White’s Medicare enrollment and rejected Dr. White’s argument that the timing of the revocation action by CMS was clearly retaliatory and intended to apply pressure on Dr. White for additional monetary penalties. ANALYSIS The USDC found CMS’ decisions to deny Dr. White enrollment in Medicare and revoke his privileges, and the subsequent Board’s affirmations were arbitrary and capricious and not supported substantial evidence. CMS did not have a legitimate reason to deny enrollment or revoke because the record does not support CMS’ assertions that Dr. White’s 2010 conviction for simple possession of a small amount of cocaine was detrimental to the best interest of the Medicare program and its beneficiaries. The USDC understood the deference it owed to administrative agencies as they adjudicate numerous complex cases before them. Yet, a court may not simply act as a rubber stamp for agency decisions. Because CMS failed to provide a reasonable basis for denying Dr. White his enrollment in Medicare or revoking his Medicare privileges, the decision of the Secretary is reversed. ZALMA OPINION A doctor should never get involved or addicted to illegal substances like Cocaine. The Fact that a doctor self reports his involvement with the drug, was rehabilitated, clean for nine years, and practices medicine legally, does not pose a danger to Medicare as do those doctors who are arrested every year for fraud. The decision of Becerra, the ALJ and the Board was clearly retaliatory and abusive and the USDC had no choice but to reverse the Board and let the doctor continue to practice medicine and charge Medicare for his services. Overreach by the administrative agency was stopped by the court. (c) 2024 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 Newsbreak.com https://www.newsbreak.com/@c/1653419?s=01; 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 Insurance Claims Library – https://lnkd.in/gwEYk
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  • Insurance Fraud Requires Doctor to Lose his License

    Read the full article at https://www.linkedin.com/pulse/insurance-fraud-requires-doctor-lose-his-license-zalma-esq-cfe-l2qkc/?trackingId=8KA%2FEXdvoGfzd13NxusOMw%3D%3D

    Sexual Misconduct, Fraud, Bribery & Unnecessary Surgery Revokes License

    Post 4927

    Louis Quartararo appealed from an August 22, 2022 final agency decision of the State Board of Medical Examiners (Board), revoking his license to practice medicine and surgery in New Jersey. The Superior Court of New Jersey, in In The Matter Of The Suspension Or Revocation Of The License Of Louis Quartararo, M.D. License No. 25MA07137700 To Practice Medicine And Surgery In The State Of New Jersey, No. A-0425-22, Superior Court of New Jersey, Appellate Division (October 31, 2024) affirmed the revocation.

    The Board charged Dr. Quartararo with engaging in sexual contact with patients; negligent acts by performing surgeries with co-surgeons who lacked the requisite privileges; and acts of fraud, deception and misrepresentation by miscoding procedures on patient operative reports and listing procedures in the reports he had not performed for the purpose of ensuring insurance coverage.

    FACTS

    Quartararo was a physician and Board-certified orthopedic surgeon licensed to practice medicine in New Jersey.

    Approximately one week before K.D. was scheduled to meet with Board investigators, Quartararo gave K.D. $20,916, which K.D. told an investigator was “for school.” Later, Quartararo’s attorney offered her more money to retract the statement she had made to the Board about her relationship with Quartararo.

    THE OAL HEARING

    At a formal hearing, the Board’s expert, Dr. Ashraf addressed Quartararo’s treatment of patient Y.O. revealed that the surgical procedures Quartararo performed were not medically necessary. In reviewing the description of Quartararo’s procedure on Y.O.’s spine, Dr. Ashraf concluded that Quartararo’s surgery on Y.O.’s completely normal spine “is gross negligence.”

    Regarding the fraud claims alleging that Quartararo had failed to properly code surgical procedures that he performed on E.S., D.C., Y.O., L.V., D.E., and V.C., Dr. Ashraf testified that the “whole function” of the “operations” section on the first page of the operative report was to list the procedures that were performed during the operation and he testified that, despite “laminotomy” appearing on the first page of V.C.’s and D.C.’s reports, their post-surgery MRIs revealed that laminotomies had not been performed.

    THE ALJ’S DECISION

    The Administrative Law Judge (ALJ) issued a comprehensive seventy-nine-page decision and concluded that Quartararo had “engaged in gross malpractice, professional misconduct, failure to comply with regulations administered by the Board, and failure to be of good moral character.”

    On August 22, 2022, the Board filed its final decision, revoking Quartararo’s license for a minimum of seven years from the date of voluntary surrender, April 5, 2019. The Board concluded that Quartararo’s “misconduct warrants a serious penalty in excess of that recommended by [the ALJ]” and that he “flagrantly ignored, and in fact shattered professional norms when he engaged in sexual misconduct with patients Y.R. and K.D.” The Board found Quartararo’s conduct was “so egregious that the only appropriate discipline is a license revocation.”

    The Board also imposed an aggregate monetary sanction of $343,909.75, comprised of a civil penalty of $90,000, $61,684.75 in costs, and $192,225 in attorney’s fees.

    Quartararo Argued

    The Board determined that revocation was warranted because he preyed on two vulnerable patients employed intimidation and coercion tactics to dissuade at least one of his victims-K.D.- from testifying about the true nature of their relation, and resorted to making threats resulting in the issuance of a temporary restraining order against him.

    Quartararo admitted he had not performed laminotomies and that he had used the laminotomy code to ensure that he would be paid by insurance carriers. He did so rather than correctly coding the procedures he actually performed because of the risk he would otherwise not be paid.

    ZALMA OPINION

    Quartararo admitted before the ALJ that he committed fraud by billing insurers for laminotomies that he did not perform. As such he admitted to committing a federal as well as a New Jersey felony that should be presented to the US Attorney and the local District Attorney for prosecution. He lost his license because he took advantage sexually of vulnerable patients, committed gross acts of malpractice and profited from knowing insurance fraud. The people of New Jersey are now safe from his criminal and unprofessional conduct for a few more years, and in my opinion he should be prosecuted and sentenced to prison for the fraud.

    (c) 2024 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 Newsbreak.com https://www.newsbreak.com/@c/1653419?s=01; 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 X @bzalma; Go to the Insurance Claims Library – https://lnkd.in/gwEYk
    Insurance Fraud Requires Doctor to Lose his License Read the full article at https://www.linkedin.com/pulse/insurance-fraud-requires-doctor-lose-his-license-zalma-esq-cfe-l2qkc/?trackingId=8KA%2FEXdvoGfzd13NxusOMw%3D%3D Sexual Misconduct, Fraud, Bribery & Unnecessary Surgery Revokes License Post 4927 Louis Quartararo appealed from an August 22, 2022 final agency decision of the State Board of Medical Examiners (Board), revoking his license to practice medicine and surgery in New Jersey. The Superior Court of New Jersey, in In The Matter Of The Suspension Or Revocation Of The License Of Louis Quartararo, M.D. License No. 25MA07137700 To Practice Medicine And Surgery In The State Of New Jersey, No. A-0425-22, Superior Court of New Jersey, Appellate Division (October 31, 2024) affirmed the revocation. The Board charged Dr. Quartararo with engaging in sexual contact with patients; negligent acts by performing surgeries with co-surgeons who lacked the requisite privileges; and acts of fraud, deception and misrepresentation by miscoding procedures on patient operative reports and listing procedures in the reports he had not performed for the purpose of ensuring insurance coverage. FACTS Quartararo was a physician and Board-certified orthopedic surgeon licensed to practice medicine in New Jersey. Approximately one week before K.D. was scheduled to meet with Board investigators, Quartararo gave K.D. $20,916, which K.D. told an investigator was “for school.” Later, Quartararo’s attorney offered her more money to retract the statement she had made to the Board about her relationship with Quartararo. THE OAL HEARING At a formal hearing, the Board’s expert, Dr. Ashraf addressed Quartararo’s treatment of patient Y.O. revealed that the surgical procedures Quartararo performed were not medically necessary. In reviewing the description of Quartararo’s procedure on Y.O.’s spine, Dr. Ashraf concluded that Quartararo’s surgery on Y.O.’s completely normal spine “is gross negligence.” Regarding the fraud claims alleging that Quartararo had failed to properly code surgical procedures that he performed on E.S., D.C., Y.O., L.V., D.E., and V.C., Dr. Ashraf testified that the “whole function” of the “operations” section on the first page of the operative report was to list the procedures that were performed during the operation and he testified that, despite “laminotomy” appearing on the first page of V.C.’s and D.C.’s reports, their post-surgery MRIs revealed that laminotomies had not been performed. THE ALJ’S DECISION The Administrative Law Judge (ALJ) issued a comprehensive seventy-nine-page decision and concluded that Quartararo had “engaged in gross malpractice, professional misconduct, failure to comply with regulations administered by the Board, and failure to be of good moral character.” On August 22, 2022, the Board filed its final decision, revoking Quartararo’s license for a minimum of seven years from the date of voluntary surrender, April 5, 2019. The Board concluded that Quartararo’s “misconduct warrants a serious penalty in excess of that recommended by [the ALJ]” and that he “flagrantly ignored, and in fact shattered professional norms when he engaged in sexual misconduct with patients Y.R. and K.D.” The Board found Quartararo’s conduct was “so egregious that the only appropriate discipline is a license revocation.” The Board also imposed an aggregate monetary sanction of $343,909.75, comprised of a civil penalty of $90,000, $61,684.75 in costs, and $192,225 in attorney’s fees. Quartararo Argued The Board determined that revocation was warranted because he preyed on two vulnerable patients employed intimidation and coercion tactics to dissuade at least one of his victims-K.D.- from testifying about the true nature of their relation, and resorted to making threats resulting in the issuance of a temporary restraining order against him. Quartararo admitted he had not performed laminotomies and that he had used the laminotomy code to ensure that he would be paid by insurance carriers. He did so rather than correctly coding the procedures he actually performed because of the risk he would otherwise not be paid. ZALMA OPINION Quartararo admitted before the ALJ that he committed fraud by billing insurers for laminotomies that he did not perform. As such he admitted to committing a federal as well as a New Jersey felony that should be presented to the US Attorney and the local District Attorney for prosecution. He lost his license because he took advantage sexually of vulnerable patients, committed gross acts of malpractice and profited from knowing insurance fraud. The people of New Jersey are now safe from his criminal and unprofessional conduct for a few more years, and in my opinion he should be prosecuted and sentenced to prison for the fraud. (c) 2024 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 Newsbreak.com https://www.newsbreak.com/@c/1653419?s=01; 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 X @bzalma; Go to the Insurance Claims Library – https://lnkd.in/gwEYk
    WWW.LINKEDIN.COM
    Insurance Fraud Requires Doctor to Lose his License
    Sexual Misconduct, Fraud, Bribery & Unnecessary Surgery Revokes License Post 4927 Posted on November 6, 2024 by Barry Zalma See the full video at https://rumble.com/v5m5s0z-insurance-fraud-requires-doctor-to-lose-his-license.
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  • Zalma’s Insurance Fraud Letter – November 1, 2024

    ZIFL – Volume 28 Number 21

    Posted on November 1, 2024 by Barry Zalma

    Post 4924

    See the full video at and at

    Subscribe to ZIFL at https://visitor.r20.constantcontact.com/manage/optin?v=001Gb86hroKqEYVdo-PWnMUkcitKvwMc3HNWiyrn6jw8ERzpnmgU_oNjTrm1U1YGZ7_ay4AZ7_mCLQBKsXokYWFyD_Xo_zMFYUMovVTCgTAs7liC1eR4LsDBrk2zBNDMBPp7Bq0VeAA-SNvk6xgrgl8dNR0BjCMTm_gE7bAycDEHwRXFAoyVjSABkXPPaG2Jb3SEvkeZXRXPDs%3D

    The Source for the Insurance Fraud Professional

    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:

    Pill Mill Doctor’s Conviction Affirmed

    HEALTH CARE FRAUD CONVICTION AFFIRMED

    ACTING AS A DR. FEEL GOOD IS A FEDERAL CRIME

    According to the Sixth Circuit Dr. David Jankowski’s medical clinics relied on several unusual billing and prescription practices, many of which were illegal and Jankowski fraudulently billed Medicare for services he did not provide and prescribed controlled substances to patients whose conditions did not call for such treatment, with some patients unlawfully trafficking their prescribed drugs.

    In United States Of America v. David Jankowski, M.D., No. 23-1404, United States Court of Appeals, Sixth Circuit (October 23, 2024) the Sixth Circuit disposed of the fraudsters claims on appeal.

    Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf

    More McClenny Moseley & Associates Issues

    This is ZIFL’s thirty sixth 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 indicate may be criminal conduct to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana.

    10/24/2024

    MMA BANKRUPTCY HEARING TO DECIDE WHETHER TRUSTEE WILL BE APPOINTED

    Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf

    Injured While Drunk on the Job Gets Workers’ Compensation Benefits

    An appellate court in New York has upheld a decision of the Workers’ Compensation Board in favor of an injured employee of an electrical contractor company because intoxication was not the sole cause of the accident.

    Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf

    Man Bites Dog Story:

    Fraudsters Arbitration Attempts Stopped

    Arbitration Stayed for Suspected Chiropractors’ Fraudulent No Fault Medical Claims

    Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf

    In Government Employees Insurance Company, (“GEICO”) v. Didier Demesmin, M.D., et al, No. 23-CV-6191 (ARR) (MMH), United States District Court, E.D. New York (October 23, 2024) GEICO sought to enjoin defendants Manuel A. Mendoza, D.C. and Mendoza Chiropractic Office PC (collectively the “Mendoza Defendants”) from pursuing certain “no-fault” insurance collection arbitrations or initiating new collections proceedings during the pendency of this lawsuit.

    Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf

    Health Insurance Fraud Convictions

    Louisiana Nursing Home Owner to Pay $8.2M for Misusing Assets During Ida

    Bob Dean Jr a Louisiana nursing home owner and several companies he operated have agreed to an $8.2 million consent judgment to resolve allegations that they misappropriated and misused the assets and income of four nursing homes in Louisiana before and after Hurricane Ida’s landfall in August 2021.

    Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf

    Officer Caught Aiding Criminals for Cash

    Police Officer who took Bribes from Insurance Fraudster Convicted

    Demarkco Johnson (“Johnson”), appealed his convictions for taking bribes about insurance fraud.

    Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf

    Convictions of Other Than Health Insurance Fraud

    Former Lake Forest Agent Convicted On 90 Counts Of Insurance Fraud After Stealing Nearly $200,000 In Premium Payments

    Karen Marie Dondanville, 56, of Mission Viejo, California, a former Lake Forest insurance agent was convicted on 90 counts of insurance fraud after stealing nearly $200,000 in premium payments.

    Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf

    The Need to Understand the Mutability of Memory

    Investigators and lawyers believe what they are told by eye witnesses who describe what he or she says with conviction. However, every professional investigator or litigator must know that memory is not necessarily accurate because very few people have a perfect eidetic (photographic) memory. Memory is a fluid and often unreliable human function.

    Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf

    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. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Write to Mr. Zalma at [email protected]; http://www.zalma.com; http://zalma.com/blog. 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

    Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf
    Zalma’s Insurance Fraud Letter – November 1, 2024 ZIFL – Volume 28 Number 21 Posted on November 1, 2024 by Barry Zalma Post 4924 See the full video at and at Subscribe to ZIFL at https://visitor.r20.constantcontact.com/manage/optin?v=001Gb86hroKqEYVdo-PWnMUkcitKvwMc3HNWiyrn6jw8ERzpnmgU_oNjTrm1U1YGZ7_ay4AZ7_mCLQBKsXokYWFyD_Xo_zMFYUMovVTCgTAs7liC1eR4LsDBrk2zBNDMBPp7Bq0VeAA-SNvk6xgrgl8dNR0BjCMTm_gE7bAycDEHwRXFAoyVjSABkXPPaG2Jb3SEvkeZXRXPDs%3D The Source for the Insurance Fraud Professional 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: Pill Mill Doctor’s Conviction Affirmed HEALTH CARE FRAUD CONVICTION AFFIRMED ACTING AS A DR. FEEL GOOD IS A FEDERAL CRIME According to the Sixth Circuit Dr. David Jankowski’s medical clinics relied on several unusual billing and prescription practices, many of which were illegal and Jankowski fraudulently billed Medicare for services he did not provide and prescribed controlled substances to patients whose conditions did not call for such treatment, with some patients unlawfully trafficking their prescribed drugs. In United States Of America v. David Jankowski, M.D., No. 23-1404, United States Court of Appeals, Sixth Circuit (October 23, 2024) the Sixth Circuit disposed of the fraudsters claims on appeal. Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf More McClenny Moseley & Associates Issues This is ZIFL’s thirty sixth 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 indicate may be criminal conduct to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana. 10/24/2024 MMA BANKRUPTCY HEARING TO DECIDE WHETHER TRUSTEE WILL BE APPOINTED Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf Injured While Drunk on the Job Gets Workers’ Compensation Benefits An appellate court in New York has upheld a decision of the Workers’ Compensation Board in favor of an injured employee of an electrical contractor company because intoxication was not the sole cause of the accident. Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf Man Bites Dog Story: Fraudsters Arbitration Attempts Stopped Arbitration Stayed for Suspected Chiropractors’ Fraudulent No Fault Medical Claims Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf In Government Employees Insurance Company, (“GEICO”) v. Didier Demesmin, M.D., et al, No. 23-CV-6191 (ARR) (MMH), United States District Court, E.D. New York (October 23, 2024) GEICO sought to enjoin defendants Manuel A. Mendoza, D.C. and Mendoza Chiropractic Office PC (collectively the “Mendoza Defendants”) from pursuing certain “no-fault” insurance collection arbitrations or initiating new collections proceedings during the pendency of this lawsuit. Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf Health Insurance Fraud Convictions Louisiana Nursing Home Owner to Pay $8.2M for Misusing Assets During Ida Bob Dean Jr a Louisiana nursing home owner and several companies he operated have agreed to an $8.2 million consent judgment to resolve allegations that they misappropriated and misused the assets and income of four nursing homes in Louisiana before and after Hurricane Ida’s landfall in August 2021. Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf Officer Caught Aiding Criminals for Cash Police Officer who took Bribes from Insurance Fraudster Convicted Demarkco Johnson (“Johnson”), appealed his convictions for taking bribes about insurance fraud. Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf Convictions of Other Than Health Insurance Fraud Former Lake Forest Agent Convicted On 90 Counts Of Insurance Fraud After Stealing Nearly $200,000 In Premium Payments Karen Marie Dondanville, 56, of Mission Viejo, California, a former Lake Forest insurance agent was convicted on 90 counts of insurance fraud after stealing nearly $200,000 in premium payments. Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf The Need to Understand the Mutability of Memory Investigators and lawyers believe what they are told by eye witnesses who describe what he or she says with conviction. However, every professional investigator or litigator must know that memory is not necessarily accurate because very few people have a perfect eidetic (photographic) memory. Memory is a fluid and often unreliable human function. Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf 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. Go to the podcast Zalma On Insurance at https://podcasters.spotify.com/pod/show/barry-zalma/support; Write to Mr. Zalma at [email protected]; http://www.zalma.com; http://zalma.com/blog. 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 Read the full article and all 18 pages of ZIFL at https://zalma.com/blog/wp-content/uploads/2024/10/ZIFL-11-01-2024.pdf
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  • Officer Caught Aiding Criminals for Cash

    Police Officer who took Bribes from Insurance Fraudster Convicted

    Post 4923

    Read the full article at https://www.linkedin.com/pulse/officer-caught-aiding-criminals-cash-barry-zalma-esq-cfe-niboc, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts.

    Demarkco Johnson (“Johnson”), appealed his convictions and claims the following errors:

    1 The trial court abused its discretion in denying appellant’s request for a jury instruction on entrapment.
    2 The trial court erred in failing to admonish and/or instruct the witness to stop answering questions with a legal conclusion after defense counsel had objected.
    3 Appellant’s convictions are against the manifest weight of the evidence; therefore, his convictions are in violation of the Ohio state constitution and the Sixth and Fourteenth Amendments to the United States Constitution.

    In State Of Ohio v. Demarkco Johnson, 2024-Ohio-5098, No. 113591, Court of Appeals of Ohio, Eighth District, Cuyahoga (October 24, 2024) resolved the issues on appeal.

    FACTS

    Defendants were charged with two counts of conspiracy, three counts of bribery, eight counts of forgery, one count of insurance fraud, one count of identity fraud, and one count of engaging in a pattern of corrupt activity. They engaged in a pattern of corrupt activity charge included a clause alleging that at least one of the incidents of corrupt activity was a felony of the third degree or higher.

    At trial George Michael Riley, Sr. (“Riley”), testified that he became a confidential source for the Federal Bureau of Investigation (“FBI”), which was investigating corruption in the East Cleveland Police Department. Special Agent Shaun Roth (“Roth”), an agent with the FBI working with the Cleveland Metropolitan Anti-Corruption Task Force, testified that the FBI executed a search warrant for one of Riley’s properties.

    Harris’s services included running Riley’s name in police databases to check for warrants and blocking off city roads so Riley could move his demolition equipment throughout the city.

    Two of Riley’s trucks were stolen from his business in East Cleveland. Riley told his contacts at the FBI, and FBI officials instructed him to file a police report with the East Cleveland police just as any other victim would do. Riley cooperated with the FBI.

    After hearing the evidence, the jury found Johnson guilty of two counts of bribery, as alleged in Counts 5 and 10 of the indictment. The jury acquitted him of all other charges. The court sentenced Johnson to 12 months in prison on both counts and ordered that the two prison terms be served concurrently. Johnson appealed the trial court’s judgment.

    Law and Analysis - Entrapment Instruction

    In the first assignment of error, Johnson argues the trial court erred in denying his request for a jury instruction on the defense of entrapment.

    Entrapment is a ‘confession and avoidance’ defense in which the defendant admits committing the acts charged but claims that the criminal design arose with the state’s agent. There is no entrapment when government officials merely afford opportunities or facilities for the commission of the offense to a criminal defendant who was predisposed to commit the offense.

    The video evidence showed Johnson handing Riley reports in exchange for money on multiple occasions. Johnson’s conduct demonstrated a ready acquiescence to the inducements offered by the government’s confidential source and a willingness to become involved in criminal activity in exchange for money.

    The evidence showed that Johnson not only had expert knowledge as to how to create the police reports in a way that could go undetected, but he also had access to the blank police forms that made the concealment of the reports possible. The Court of Appeals found that evidence did not support an entrapment defense.

    Testimony Pertaining to Bribery

    In the second assignment of error, Johnson argues the trial court erred by refusing to instruct Roth to refrain from using the word “bribe” or “bribery payment” in response to questions that were not specifically related to bribe payments. Even if Roth had avoided the words “bribe” or “bribery payment,” the outcome of the trial would not have been any different. The overwhelming evidence established that Johnson helped create fake police reports in exchange for money.

    Manifest Weight of the Evidence

    Johnson argued his convictions were against the manifest weight of the evidence.

    The Court of Appeals noted that Johnson’s convictions were not dependent on his knowledge of any insurance scheme or Harris’s separate dealings with Riley. His convictions were based solely on his position as a police officer in the East Cleveland Police Department and his acceptance of cash in exchange for police reports. Video evidence showed Johnson accepting cash from Riley in exchange for the reports on at least two occasions. And, despite Johnson’s argument to the contrary, Johnson played along when Harris introduced him to Riley as Nevels.

    CONCLUSION

    The Court of Appeals ordered that a special mandate issue out of the court directing the common pleas court to carry this judgment into execution. The defendant’s conviction having been affirmed, any bail pending appeal is terminated. Case remanded to the trial court for execution of sentence.

    ZALMA OPINION

    There can be no excuse for a police officer to sell information to an insurance criminal to ease the ability of the crime to succeed. Officer Johnson tried multiple arguments to set aside his conviction even though the evidence against him was overwhelming. The Court of Appeals disposed of his arguments quickly and intelligently. Fraud is a crime. Insurance fraud is a crime. Helping the criminal avoid prosecution is also a crime and establishes the officer had given up his honor for cash.

    (c) 2024 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 Newsbreak.com https://www.newsbreak.com/@c/1653419?s=01; 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 Insurance Claims Library – https://lnkd.in/gwEYk
    Officer Caught Aiding Criminals for Cash Police Officer who took Bribes from Insurance Fraudster Convicted Post 4923 Read the full article at https://www.linkedin.com/pulse/officer-caught-aiding-criminals-cash-barry-zalma-esq-cfe-niboc, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts. Demarkco Johnson (“Johnson”), appealed his convictions and claims the following errors: 1 The trial court abused its discretion in denying appellant’s request for a jury instruction on entrapment. 2 The trial court erred in failing to admonish and/or instruct the witness to stop answering questions with a legal conclusion after defense counsel had objected. 3 Appellant’s convictions are against the manifest weight of the evidence; therefore, his convictions are in violation of the Ohio state constitution and the Sixth and Fourteenth Amendments to the United States Constitution. In State Of Ohio v. Demarkco Johnson, 2024-Ohio-5098, No. 113591, Court of Appeals of Ohio, Eighth District, Cuyahoga (October 24, 2024) resolved the issues on appeal. FACTS Defendants were charged with two counts of conspiracy, three counts of bribery, eight counts of forgery, one count of insurance fraud, one count of identity fraud, and one count of engaging in a pattern of corrupt activity. They engaged in a pattern of corrupt activity charge included a clause alleging that at least one of the incidents of corrupt activity was a felony of the third degree or higher. At trial George Michael Riley, Sr. (“Riley”), testified that he became a confidential source for the Federal Bureau of Investigation (“FBI”), which was investigating corruption in the East Cleveland Police Department. Special Agent Shaun Roth (“Roth”), an agent with the FBI working with the Cleveland Metropolitan Anti-Corruption Task Force, testified that the FBI executed a search warrant for one of Riley’s properties. Harris’s services included running Riley’s name in police databases to check for warrants and blocking off city roads so Riley could move his demolition equipment throughout the city. Two of Riley’s trucks were stolen from his business in East Cleveland. Riley told his contacts at the FBI, and FBI officials instructed him to file a police report with the East Cleveland police just as any other victim would do. Riley cooperated with the FBI. After hearing the evidence, the jury found Johnson guilty of two counts of bribery, as alleged in Counts 5 and 10 of the indictment. The jury acquitted him of all other charges. The court sentenced Johnson to 12 months in prison on both counts and ordered that the two prison terms be served concurrently. Johnson appealed the trial court’s judgment. Law and Analysis - Entrapment Instruction In the first assignment of error, Johnson argues the trial court erred in denying his request for a jury instruction on the defense of entrapment. Entrapment is a ‘confession and avoidance’ defense in which the defendant admits committing the acts charged but claims that the criminal design arose with the state’s agent. There is no entrapment when government officials merely afford opportunities or facilities for the commission of the offense to a criminal defendant who was predisposed to commit the offense. The video evidence showed Johnson handing Riley reports in exchange for money on multiple occasions. Johnson’s conduct demonstrated a ready acquiescence to the inducements offered by the government’s confidential source and a willingness to become involved in criminal activity in exchange for money. The evidence showed that Johnson not only had expert knowledge as to how to create the police reports in a way that could go undetected, but he also had access to the blank police forms that made the concealment of the reports possible. The Court of Appeals found that evidence did not support an entrapment defense. Testimony Pertaining to Bribery In the second assignment of error, Johnson argues the trial court erred by refusing to instruct Roth to refrain from using the word “bribe” or “bribery payment” in response to questions that were not specifically related to bribe payments. Even if Roth had avoided the words “bribe” or “bribery payment,” the outcome of the trial would not have been any different. The overwhelming evidence established that Johnson helped create fake police reports in exchange for money. Manifest Weight of the Evidence Johnson argued his convictions were against the manifest weight of the evidence. The Court of Appeals noted that Johnson’s convictions were not dependent on his knowledge of any insurance scheme or Harris’s separate dealings with Riley. His convictions were based solely on his position as a police officer in the East Cleveland Police Department and his acceptance of cash in exchange for police reports. Video evidence showed Johnson accepting cash from Riley in exchange for the reports on at least two occasions. And, despite Johnson’s argument to the contrary, Johnson played along when Harris introduced him to Riley as Nevels. CONCLUSION The Court of Appeals ordered that a special mandate issue out of the court directing the common pleas court to carry this judgment into execution. The defendant’s conviction having been affirmed, any bail pending appeal is terminated. Case remanded to the trial court for execution of sentence. ZALMA OPINION There can be no excuse for a police officer to sell information to an insurance criminal to ease the ability of the crime to succeed. Officer Johnson tried multiple arguments to set aside his conviction even though the evidence against him was overwhelming. The Court of Appeals disposed of his arguments quickly and intelligently. Fraud is a crime. Insurance fraud is a crime. Helping the criminal avoid prosecution is also a crime and establishes the officer had given up his honor for cash. (c) 2024 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 Newsbreak.com https://www.newsbreak.com/@c/1653419?s=01; 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 Insurance Claims Library – https://lnkd.in/gwEYk
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  • Who’s on First & in What Percentage

    Application of Diverse “Other Insurance” Clauses
    Insurers Protected Insured and Litigated Their Differences

    Post 4920

    Two insurance companies- Gemini and Zurich- asked the Eleventh Circuit Court of Appeal to determine what share of a $2 million settlement each is required to pay. The district court entered judgment for Gemini, ordering that Zurich pay $500,000 plus prejudgment interest. Both parties appealed, with Gemini seeking another $500,000 and Zurich challenging the award of prejudgment interest.

    In Gemini Insurance Company v. Zurich American Insurance Company, No. 22-13495, United States Court of Appeals, Eleventh Circuit (October 23, 2024) the competing “other insurance clauses” were resolved.
    FACTS

    After the death of Josue Vallejo, who was struck by a tractor-trailer operated by an employee of FSR Trucking, Inc two of three insurers disputed what proportion of the settlement each should pay. Zurich insured FSR, through its coverage of Commercial, for $1 million. Gemini also insured FSR for $3 million.

    The Vallejo claim settled for $3 million, of which Gemini contributed $2 million. Ryder’s insurance company, which is not a party to this appeal, contributed the other $1 million. Gemini and Zurich agree that they each owe a share of the $2 million, but dispute how much each one must pay. Under Gemini’s theory, they each owe $1 million. Under Zurich’s theory, they each owe their pro rata share, which is $500,000 for Zurich and $1.5 million for Gemini.

    The different theories of coverage turn on the application of the two policies’ “other insurance” clauses, which generally function to apportion coverage when there is overlapping insurance. Gemini argues that its policy is excess to Zurich’s, while Zurich argues that the policies attach at the same level and thus trigger pro rata contribution.

    Gemini sued Zurich for a declaratory judgment in its favor and an award of $1 million plus interest under claims of contractual subrogation or equitable subrogation/contribution. Zurich tendered $500,000 to Gemini to satisfy its pro rata share. Gemini, however, continued to litigate for the other $500,000 plus interest on the entire amount.

    Gemini appealed the District Court’s ruling in favor of Zurich and sought to obtain the other $500,000.

    ANALYSIS

    In Florida, where more than one insurer’s policy provides coverage for a loss, as the parties agree is the case here, it is appropriate to review the insurance contracts to see if the documents address the ‘ranking’ or contribution of other insurers.
    The Other Insurance Clauses

    Gemini’s “other insurance” clause provides: “This insurance is excess over and shall not contribute with any of the other insurance, whether primary, excess, contingent or on any other basis. This condition will not apply to insurance specifically written as excess over this policy.”

    Zurich’s “other insurance” clause is slightly different. “When this Coverage Form and any other Coverage Form or policy covers on the same basis, either excess or primary, we will pay only our share. Our share is the proportion that the Limit of Insurance of our Coverage Form bears to the total of the limits of all the Coverage Forms and policies covering on the same basis.

    Interpretation of the “Other Insurance” Clauses

    Where two insurance policies contain excess insurance clauses the clauses are deemed mutually repugnant and both insurers become primary and share the loss on a pro rata basis in accordance with their policy limits. Zurich argued, and the district court agreed, that both policies contain excess clauses such as pro rata contribution results.

    The Eleventh Circuit Court of Appeals sided with Gemini because when two policies containing conflicting “other insurance” or excess [uninsured/underinsured motorist] clauses.

    In sum an “other insurance” clause containing the phrase “we will pay the proportion of damages payable as excess” means that the clause was pro rata, even though it also characterized itself as an excess clause. Moreover, the Eleventh Circuit concluded both policies were primary.

    The Eleventh Circuit reversed the district court’s resolution of the cross-motions for summary judgment with regard to the amount of contribution and remanded the case for entry of judgment in favor of Gemini for the principal amount of $1,000,000, with the understanding that Zurich has already paid half of that sum. Upon entry of the amended final judgment on remand, Gemini will be the prevailing party. When a verdict liquidates damages on a plaintiff’s out-of-pocket, pecuniary losses, plaintiff is entitled, as a matter of law, to prejudgment interest at the statutory rate from the date of that loss.

    The Eleventh Circuit reversed the district court’s resolution of the cross-motions for summary judgment and remanded for the court to enter judgment in favor of Gemini in the principal amount of $1,000,000 understanding that Zurich has already paid $500,000. It also affirmed the award of prejudgment interest on the first $500,000 and direct the court to award Gemini prejudgment interest on the second $500,000 from February 7, 2019, until the date of the amended final judgment.

    ZALMA OPINION

    The three insurers of the defendant did the right thing by protecting the insured and then resolving their dispute over the share owed in court. Although insurance companies, generally, should not sue each other. “Other Insurance” clauses invariably raise disputes between insurers and often cause hardship to the insured. In this case Gemini, Zurich and an unnamed insurer put up the $3 million to settle and then Gemini and Zurich sued to clarify who owed what. The Eleventh Circuit found that the District Court was wrong because interpreting the competing “other insurance” clauses should have resulted in a finding that both Gemini and Zurich were primary insurers and each owed $1 million of the settlement and Zurich owed Gemini $500,000 plus interest.

    (c) 2024 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 Newsbreak.com https://www.newsbreak.com/@c/1653419?s=01; 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 Insurance Claims Library – https://lnkd.in/gwEYk
    Who’s on First & in What Percentage Application of Diverse “Other Insurance” Clauses Insurers Protected Insured and Litigated Their Differences Post 4920 Two insurance companies- Gemini and Zurich- asked the Eleventh Circuit Court of Appeal to determine what share of a $2 million settlement each is required to pay. The district court entered judgment for Gemini, ordering that Zurich pay $500,000 plus prejudgment interest. Both parties appealed, with Gemini seeking another $500,000 and Zurich challenging the award of prejudgment interest. In Gemini Insurance Company v. Zurich American Insurance Company, No. 22-13495, United States Court of Appeals, Eleventh Circuit (October 23, 2024) the competing “other insurance clauses” were resolved. FACTS After the death of Josue Vallejo, who was struck by a tractor-trailer operated by an employee of FSR Trucking, Inc two of three insurers disputed what proportion of the settlement each should pay. Zurich insured FSR, through its coverage of Commercial, for $1 million. Gemini also insured FSR for $3 million. The Vallejo claim settled for $3 million, of which Gemini contributed $2 million. Ryder’s insurance company, which is not a party to this appeal, contributed the other $1 million. Gemini and Zurich agree that they each owe a share of the $2 million, but dispute how much each one must pay. Under Gemini’s theory, they each owe $1 million. Under Zurich’s theory, they each owe their pro rata share, which is $500,000 for Zurich and $1.5 million for Gemini. The different theories of coverage turn on the application of the two policies’ “other insurance” clauses, which generally function to apportion coverage when there is overlapping insurance. Gemini argues that its policy is excess to Zurich’s, while Zurich argues that the policies attach at the same level and thus trigger pro rata contribution. Gemini sued Zurich for a declaratory judgment in its favor and an award of $1 million plus interest under claims of contractual subrogation or equitable subrogation/contribution. Zurich tendered $500,000 to Gemini to satisfy its pro rata share. Gemini, however, continued to litigate for the other $500,000 plus interest on the entire amount. Gemini appealed the District Court’s ruling in favor of Zurich and sought to obtain the other $500,000. ANALYSIS In Florida, where more than one insurer’s policy provides coverage for a loss, as the parties agree is the case here, it is appropriate to review the insurance contracts to see if the documents address the ‘ranking’ or contribution of other insurers. The Other Insurance Clauses Gemini’s “other insurance” clause provides: “This insurance is excess over and shall not contribute with any of the other insurance, whether primary, excess, contingent or on any other basis. This condition will not apply to insurance specifically written as excess over this policy.” Zurich’s “other insurance” clause is slightly different. “When this Coverage Form and any other Coverage Form or policy covers on the same basis, either excess or primary, we will pay only our share. Our share is the proportion that the Limit of Insurance of our Coverage Form bears to the total of the limits of all the Coverage Forms and policies covering on the same basis. Interpretation of the “Other Insurance” Clauses Where two insurance policies contain excess insurance clauses the clauses are deemed mutually repugnant and both insurers become primary and share the loss on a pro rata basis in accordance with their policy limits. Zurich argued, and the district court agreed, that both policies contain excess clauses such as pro rata contribution results. The Eleventh Circuit Court of Appeals sided with Gemini because when two policies containing conflicting “other insurance” or excess [uninsured/underinsured motorist] clauses. In sum an “other insurance” clause containing the phrase “we will pay the proportion of damages payable as excess” means that the clause was pro rata, even though it also characterized itself as an excess clause. Moreover, the Eleventh Circuit concluded both policies were primary. The Eleventh Circuit reversed the district court’s resolution of the cross-motions for summary judgment with regard to the amount of contribution and remanded the case for entry of judgment in favor of Gemini for the principal amount of $1,000,000, with the understanding that Zurich has already paid half of that sum. Upon entry of the amended final judgment on remand, Gemini will be the prevailing party. When a verdict liquidates damages on a plaintiff’s out-of-pocket, pecuniary losses, plaintiff is entitled, as a matter of law, to prejudgment interest at the statutory rate from the date of that loss. The Eleventh Circuit reversed the district court’s resolution of the cross-motions for summary judgment and remanded for the court to enter judgment in favor of Gemini in the principal amount of $1,000,000 understanding that Zurich has already paid $500,000. It also affirmed the award of prejudgment interest on the first $500,000 and direct the court to award Gemini prejudgment interest on the second $500,000 from February 7, 2019, until the date of the amended final judgment. ZALMA OPINION The three insurers of the defendant did the right thing by protecting the insured and then resolving their dispute over the share owed in court. Although insurance companies, generally, should not sue each other. “Other Insurance” clauses invariably raise disputes between insurers and often cause hardship to the insured. In this case Gemini, Zurich and an unnamed insurer put up the $3 million to settle and then Gemini and Zurich sued to clarify who owed what. The Eleventh Circuit found that the District Court was wrong because interpreting the competing “other insurance” clauses should have resulted in a finding that both Gemini and Zurich were primary insurers and each owed $1 million of the settlement and Zurich owed Gemini $500,000 plus interest. (c) 2024 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 Newsbreak.com https://www.newsbreak.com/@c/1653419?s=01; 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 Insurance Claims Library – https://lnkd.in/gwEYk
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    A series of writings and/or videos to help understand insurance, insurance claims, and becoming an insurance claims professional and who need to provide or receive competent and Excellence in Claims Handling. Click to read Excellence in Claims Handling, by Barry Zalma, a Substack publication with thousands of subscribers.
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  • *Elon Musk* recently exposed that *George Soros* is attempting to purchase 200 U.S. radio stations right before the election. This is controversial due to *Federal Communications Commission (FCC)* fast-tracking the process, allowing Soros to bypass lengthy reviews. *FCC Commissioner Brendan Carr* criticized the move, calling it a blatant attempt to control local media and push **left-wing propaganda**.

    - *Kamala Harris’* Arizona campaign office was reportedly shot at, but there were no injuries. Although the shooting didn’t appear to be an assassination attempt, it highlights growing political tensions. In contrast, Harris has faced criticism from *President Biden**, who admitted she has been handling major decisions, from **foreign policy* to *domestic policy**, implying that Harris is responsible for issues like the **border crisis* and rising **gas prices**.

    - Rumors about *Donald Trump* canceling a meeting with *Ukrainian President Zelensky* have emerged after Zelensky criticized Trump’s handling of the war. Trump retaliated by accusing Zelensky of refusing to strike a deal, implying that U.S. funding may dwindle if Zelensky continues alienating him. *Trump* has also promised to implement a 100% tariff on *Mexican car imports* to create more jobs for Americans, further emphasizing his *pro-America* stance.

    - *House Speaker Mike Johnson* and *Majority Leader Chuck Schumer* passed a three-month government funding bill under pressure from an upcoming hurricane in Florida. This temporary measure will keep the government running until after the election, giving *Republicans* leverage if they win.

    - *Tax Network USA* is offering help to those who owe back taxes as the *IRS* has increased its enforcement efforts in 2024. With over 5 million letters sent to taxpayers with unpaid debts, it’s crucial to seek professional assistance. *Tax Network USA* has saved clients over $1 billion and offers free consultations.

    - *Thomas Massie**, a **Libertarian-leaning Republican**, questioned the **Inspector General* on the *January 6th Capitol breach* and revealed that the *FBI* was deeply involved. This information has allegedly been suppressed to damage *Trump’s reputation* before the election.

    - In international news, *Israel* has expanded its military operations into *Lebanon* amid escalating tensions with **Hezbollah**. **John Kirby**, the **White House National Security Spokesman**, reaffirmed the U.S. support for Israel, citing threats from Iran as a legitimate concern.

    - As *Zelensky* seeks more funding from *President Biden* to support **Ukraine**, Russian forces have made significant gains in **eastern Ukraine**, particularly around the town of **Vuhledar**, putting Zelensky in a tough position to request further aid from the U.S.

    https://www.youtube.com/watch?v=mFuIBugZkxw
    *Elon Musk* recently exposed that *George Soros* is attempting to purchase 200 U.S. radio stations right before the election. This is controversial due to *Federal Communications Commission (FCC)* fast-tracking the process, allowing Soros to bypass lengthy reviews. *FCC Commissioner Brendan Carr* criticized the move, calling it a blatant attempt to control local media and push **left-wing propaganda**. - *Kamala Harris’* Arizona campaign office was reportedly shot at, but there were no injuries. Although the shooting didn’t appear to be an assassination attempt, it highlights growing political tensions. In contrast, Harris has faced criticism from *President Biden**, who admitted she has been handling major decisions, from **foreign policy* to *domestic policy**, implying that Harris is responsible for issues like the **border crisis* and rising **gas prices**. - Rumors about *Donald Trump* canceling a meeting with *Ukrainian President Zelensky* have emerged after Zelensky criticized Trump’s handling of the war. Trump retaliated by accusing Zelensky of refusing to strike a deal, implying that U.S. funding may dwindle if Zelensky continues alienating him. *Trump* has also promised to implement a 100% tariff on *Mexican car imports* to create more jobs for Americans, further emphasizing his *pro-America* stance. - *House Speaker Mike Johnson* and *Majority Leader Chuck Schumer* passed a three-month government funding bill under pressure from an upcoming hurricane in Florida. This temporary measure will keep the government running until after the election, giving *Republicans* leverage if they win. - *Tax Network USA* is offering help to those who owe back taxes as the *IRS* has increased its enforcement efforts in 2024. With over 5 million letters sent to taxpayers with unpaid debts, it’s crucial to seek professional assistance. *Tax Network USA* has saved clients over $1 billion and offers free consultations. - *Thomas Massie**, a **Libertarian-leaning Republican**, questioned the **Inspector General* on the *January 6th Capitol breach* and revealed that the *FBI* was deeply involved. This information has allegedly been suppressed to damage *Trump’s reputation* before the election. - In international news, *Israel* has expanded its military operations into *Lebanon* amid escalating tensions with **Hezbollah**. **John Kirby**, the **White House National Security Spokesman**, reaffirmed the U.S. support for Israel, citing threats from Iran as a legitimate concern. - As *Zelensky* seeks more funding from *President Biden* to support **Ukraine**, Russian forces have made significant gains in **eastern Ukraine**, particularly around the town of **Vuhledar**, putting Zelensky in a tough position to request further aid from the U.S. https://www.youtube.com/watch?v=mFuIBugZkxw
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