• Zalma’s Insurance Fraud Letter September 15, 2024

    Zalma’s Insurance Fraud Letter

    A ClaimSchoolâ„ĸ Publication Š 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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  • Bad Faith Set Up Fails

    Read the full article at https://www.linkedin.com/pulse/bad-faith-set-up-fails-barry-zalma-esq-cfe-jllxc, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts.
    Inadequate Information Made Refusal to Pay Policy Limits Not Bad Faith

    INADEQUATE MEDICAL AUTHORIZATION USED TO CAUSE INSURER TO REFUSE SETTLEMENT DEMAND

    Post 4930

    Kara Flick appealed from the judgment after a jury rejected her claims for breach of contract and breach of the implied covenant of good faith and fair dealing. Flick contends the judgment should be reversed due to juror misconduct.

    In KARA FLICK v. UNITED SERVICES AUTOMOBILE ASSOCIATION, B330507, California Court of Appeals, Second District, Sixth Division (November 5, 2024) the Court of Appeals resolved the dispute.

    FACTUAL HISTORY

    After sustaining injuries in an automobile accident caused by Francisco Reyes, Jr., Flick had her attorney send Reyes's insurer, the United Services Automobile Association (USAA), a letter explaining the severity of her injuries and an authorization for the release of her medical records. Flick's attorney followed up with a settlement demand two months later, requesting that USAA pay Flick the entirety of Reyes's $100,000 policy limit in exchange for a release of liability. Attached to the demand was a single medical record from Flick's neurologist.

    USAA investigated Flick's claim and determined it did not have sufficient information to accept or reject her demand. Flick then filed a personal injury lawsuit against Reyes. The jury found in her favor and awarded nearly $1.7 million in damages.

    Flick, with an assignment from the Reyes, sued USAA for breach of contract and breach of the implied covenant of good faith and fair dealing.

    TRIAL

    At trial, a USAA claims adjustor admitted that Reyes was fully at fault for the accident with Flick. Reyes could therefore be exposed to liability in excess of his policy limits-if Flick provided sufficient documentation to support her claim.

    USAA's expert on insurance claims handling and another of its claims service managers both agreed with the supervisor that Flick's authorization was invalid and inadequate to allow USAA to obtain Flick's medical records.

    USAA needed additional records before it could determine the value of Flick's claim. Those records could have included the medical bills Flick provided to her own insurance company, the multiple doctor's notes she had excusing her from work, or the thumb drive recording her purported speech problems, all of which were entered into evidence at her personal injury trial. Because they were not provided to USAA, it was "very difficult to place a value on" Flick's claim.

    Flick's expert testified that USAA's handling of the settlement demand "was clearly unreasonable."

    Flick also did not respond to USAA's requests for additional information.

    By a vote of nine to three, the jury found that Flick did not make a reasonable settlement demand of USAA and rejected her claims for breach of contract and breach of the implied covenant of good faith and fair dealing. The trial court polled the jury, and each juror confirmed their vote.

    DISCUSSION

    The Court of Appeals concluded the trial court did not abuse its discretion in denying Flick's new trial motion. USAA successfully rebutted the presumption of prejudice by showing there is no reasonable probability that the juror, D.C.'s misconduct by not explaining he did not hear all of the adjuster's testimony, actually harmed Flick.

    Much of the adjustor's testimony consisted of facts regarding his communications with Flick's attorney - facts that were undisputed.

    What was disputed-whether Flick's settlement demand was reasonable-was the subject of other witness testimony, including USAA's expert on insurance claims handling, its supervising claims service manager, Flick's personal injury attorney, and her expert witness on insurance claims handling.

    What the admitted evidence showed was that D.C. confirmed multiple times that he voted that Flick did not make a reasonable settlement demand:

    Based on this record there was no reasonable probability that D.C.'s alleged juror misconduct actually harmed Flick.

    ZALMA OPINION

    The tort of bad faith arose from abuse by insurers on those they insured. Since its adoption in California about three quarters of a century ago, the abuse has been turned on to insurers. Ms. Flick's counsel placed a demand for settlement on USAA that it could not reasonably and in good faith to its insured, Reyes, because it was incomplete and inadequately supported and forced Flick and Reyes go through a trial where she received an uncollectible judgment against Reyes in hopes of a gigantic bad faith judgment. After much litigation and USAA spending a great deal to defend itself she received the $100,000 policy limit. USAA was punished but neither Flick nor her lawyers profited from the scheme or the appeal.

    (c) 2024 Barry Zalma & ClaimSchool, Inc.

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    Bad Faith Set Up Fails Read the full article at https://www.linkedin.com/pulse/bad-faith-set-up-fails-barry-zalma-esq-cfe-jllxc, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts. Inadequate Information Made Refusal to Pay Policy Limits Not Bad Faith INADEQUATE MEDICAL AUTHORIZATION USED TO CAUSE INSURER TO REFUSE SETTLEMENT DEMAND Post 4930 Kara Flick appealed from the judgment after a jury rejected her claims for breach of contract and breach of the implied covenant of good faith and fair dealing. Flick contends the judgment should be reversed due to juror misconduct. In KARA FLICK v. UNITED SERVICES AUTOMOBILE ASSOCIATION, B330507, California Court of Appeals, Second District, Sixth Division (November 5, 2024) the Court of Appeals resolved the dispute. FACTUAL HISTORY After sustaining injuries in an automobile accident caused by Francisco Reyes, Jr., Flick had her attorney send Reyes's insurer, the United Services Automobile Association (USAA), a letter explaining the severity of her injuries and an authorization for the release of her medical records. Flick's attorney followed up with a settlement demand two months later, requesting that USAA pay Flick the entirety of Reyes's $100,000 policy limit in exchange for a release of liability. Attached to the demand was a single medical record from Flick's neurologist. USAA investigated Flick's claim and determined it did not have sufficient information to accept or reject her demand. Flick then filed a personal injury lawsuit against Reyes. The jury found in her favor and awarded nearly $1.7 million in damages. Flick, with an assignment from the Reyes, sued USAA for breach of contract and breach of the implied covenant of good faith and fair dealing. TRIAL At trial, a USAA claims adjustor admitted that Reyes was fully at fault for the accident with Flick. Reyes could therefore be exposed to liability in excess of his policy limits-if Flick provided sufficient documentation to support her claim. USAA's expert on insurance claims handling and another of its claims service managers both agreed with the supervisor that Flick's authorization was invalid and inadequate to allow USAA to obtain Flick's medical records. USAA needed additional records before it could determine the value of Flick's claim. Those records could have included the medical bills Flick provided to her own insurance company, the multiple doctor's notes she had excusing her from work, or the thumb drive recording her purported speech problems, all of which were entered into evidence at her personal injury trial. Because they were not provided to USAA, it was "very difficult to place a value on" Flick's claim. Flick's expert testified that USAA's handling of the settlement demand "was clearly unreasonable." Flick also did not respond to USAA's requests for additional information. By a vote of nine to three, the jury found that Flick did not make a reasonable settlement demand of USAA and rejected her claims for breach of contract and breach of the implied covenant of good faith and fair dealing. The trial court polled the jury, and each juror confirmed their vote. DISCUSSION The Court of Appeals concluded the trial court did not abuse its discretion in denying Flick's new trial motion. USAA successfully rebutted the presumption of prejudice by showing there is no reasonable probability that the juror, D.C.'s misconduct by not explaining he did not hear all of the adjuster's testimony, actually harmed Flick. Much of the adjustor's testimony consisted of facts regarding his communications with Flick's attorney - facts that were undisputed. What was disputed-whether Flick's settlement demand was reasonable-was the subject of other witness testimony, including USAA's expert on insurance claims handling, its supervising claims service manager, Flick's personal injury attorney, and her expert witness on insurance claims handling. What the admitted evidence showed was that D.C. confirmed multiple times that he voted that Flick did not make a reasonable settlement demand: Based on this record there was no reasonable probability that D.C.'s alleged juror misconduct actually harmed Flick. ZALMA OPINION The tort of bad faith arose from abuse by insurers on those they insured. Since its adoption in California about three quarters of a century ago, the abuse has been turned on to insurers. Ms. Flick's counsel placed a demand for settlement on USAA that it could not reasonably and in good faith to its insured, Reyes, because it was incomplete and inadequately supported and forced Flick and Reyes go through a trial where she received an uncollectible judgment against Reyes in hopes of a gigantic bad faith judgment. After much litigation and USAA spending a great deal to defend itself she received the $100,000 policy limit. USAA was punished but neither Flick nor her lawyers profited from the scheme or the appeal. (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
    WWW.LINKEDIN.COM
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    Discover 100 collaborative articles on domains such as Marketing, Public Administration, and Healthcare. Our expertly curated collection combines AI-generated content with insights and advice from industry experts, providing you with unique perspectives and up-to-date information on many skills and their applications.
    0 Reacties 0 aandelen 2K Views
  • https://forex-strategy.com/2024/11/12/trump-supporters-are-once-again-in-danger-of-a-new-movement/
    Mental deviation in liberal women reaches new heights.
    Trump supporters are once again in danger of a new movement.
    In the article you will see what crazy women look like. Their hatred is extremely strong and there are no limits or laws for them.
    #trump #democrats #republicans #usa #politics #liberal
    https://forex-strategy.com/2024/11/12/trump-supporters-are-once-again-in-danger-of-a-new-movement/ Mental deviation in liberal women reaches new heights. Trump supporters are once again in danger of a new movement. In the article you will see what crazy women look like. Their hatred is extremely strong and there are no limits or laws for them. #trump #democrats #republicans #usa #politics #liberal
    FOREX-STRATEGY.COM
    Trump supporters are once again in danger of a new movement
    In the article you will see what crazy women look like. Their hatred is extremely strong and there are no limits or laws for them.
    0 Reacties 0 aandelen 551 Views
  • PRESIDENT TRUMP video!

    THE END OF THE DEEP STATE:

    President Trump’s Plan to Dismantle the Deep State and Return Power to the American People. Here's my plan to dismantle the deep state and reclaim our democracy from Washington corruption once and for all, and corruption it is.

    First, I will immediately re-issue my 2020 Executive Order restoring the President's authority to remove rogue bureaucrats. And I will wield that power very aggressively.

    Second, we will clean out all of the corrupt actors in our National Security and Intelligence apparatus, and there are plenty of them. The departments and agencies that have been weaponized will be completely overhauled so that faceless bureaucrats will never again be able to target and persecute conservatives, Christians, or the left's political enemies, which they're doing now at a level that nobody can believe even possible.

    Third, we will totally reform FISA courts which are so corrupt that the judges seemingly do not care when they are lied to in warrant applications. So many judges have seen so many applications that they know were wrong, or at least they must have known. They do nothing about it, they're lied to.

    Fourth, to expose the hoaxes and abuses of power that have been tearing our country apart, we will establish a Truth and Reconciliation Commission to declassify and publish all documents on Deep State spying, censorship, and corruption, and there are plenty of them.

    Fifth, we will launch a major crackdown on government leakers who collude with the fake news to deliberately weave false narratives and to subvert our government and our democracy. When possible, we will press criminal charges.

    Sixth, we will make every Inspector General's Office independent and physically separated from the departments they oversee so they do not become the protectors of the Deep State.

    Seventh, I will ask Congress to establish an independent auditing system to continually monitor our intelligence agencies to ensure they are not spying on our citizens or running disinformation campaigns against the American people, or that they are not spying on someone's campaign like they spied on my campaign.

    Eighth, we will continue the effort launched by the Trump administration to move parts of the sprawling federal bureaucracy to new locations outside the Washington Swamp. Just as I moved the Bureau of Land Management to Colorado, as many as 100,000 government positions can be moved out. And I mean immediately out of Washington to places filled with patriots who love America, and they really do love America.

    Ninth, I will work to ban federal bureaucrats from taking jobs at the companies they deal with and that they regulate. So they deal with these companies and they regulate these companies and then they want to take jobs from these companies. Doesn't work that way—such a public display cannot go on and it's taking place all the time, like with Big Pharma.

    Finally, I will push a constitutional amendment to impose term limits on members of Congress.

    This is how I will shatter the deep state and restore government that is controlled by the people and for the people.

    Thank you very much.

    https://substack.com/@randpaulreview/note/c-76114041
    PRESIDENT TRUMP video! THE END OF THE DEEP STATE: President Trump’s Plan to Dismantle the Deep State and Return Power to the American People. Here's my plan to dismantle the deep state and reclaim our democracy from Washington corruption once and for all, and corruption it is. First, I will immediately re-issue my 2020 Executive Order restoring the President's authority to remove rogue bureaucrats. And I will wield that power very aggressively. Second, we will clean out all of the corrupt actors in our National Security and Intelligence apparatus, and there are plenty of them. The departments and agencies that have been weaponized will be completely overhauled so that faceless bureaucrats will never again be able to target and persecute conservatives, Christians, or the left's political enemies, which they're doing now at a level that nobody can believe even possible. Third, we will totally reform FISA courts which are so corrupt that the judges seemingly do not care when they are lied to in warrant applications. So many judges have seen so many applications that they know were wrong, or at least they must have known. They do nothing about it, they're lied to. Fourth, to expose the hoaxes and abuses of power that have been tearing our country apart, we will establish a Truth and Reconciliation Commission to declassify and publish all documents on Deep State spying, censorship, and corruption, and there are plenty of them. Fifth, we will launch a major crackdown on government leakers who collude with the fake news to deliberately weave false narratives and to subvert our government and our democracy. When possible, we will press criminal charges. Sixth, we will make every Inspector General's Office independent and physically separated from the departments they oversee so they do not become the protectors of the Deep State. Seventh, I will ask Congress to establish an independent auditing system to continually monitor our intelligence agencies to ensure they are not spying on our citizens or running disinformation campaigns against the American people, or that they are not spying on someone's campaign like they spied on my campaign. Eighth, we will continue the effort launched by the Trump administration to move parts of the sprawling federal bureaucracy to new locations outside the Washington Swamp. Just as I moved the Bureau of Land Management to Colorado, as many as 100,000 government positions can be moved out. And I mean immediately out of Washington to places filled with patriots who love America, and they really do love America. Ninth, I will work to ban federal bureaucrats from taking jobs at the companies they deal with and that they regulate. So they deal with these companies and they regulate these companies and then they want to take jobs from these companies. Doesn't work that way—such a public display cannot go on and it's taking place all the time, like with Big Pharma. Finally, I will push a constitutional amendment to impose term limits on members of Congress. This is how I will shatter the deep state and restore government that is controlled by the people and for the people. Thank you very much. https://substack.com/@randpaulreview/note/c-76114041
    SUBSTACK.COM
    Rand Paul Review on Substack
    THE END OF THE DEEP STATE: President Trump’s Plan to Dismantle the Deep State and Return Power to the American People. Here's my plan to dismantle the deep state and reclaim our democracy from Washington corruption once and for all, and corruption it is. First, I will immediately re-issue my 2020 Executive Order restoring the President's authority to remove rogue bureaucrats. And I will wield that power very aggressively. Second, we will clean out all of the corrupt actors in our National Security and Intelligence apparatus, and there are plenty of them. The departments and agencies that have been weaponized will be completely overhauled so that faceless bureaucrats will never again be able to target and persecute conservatives, Christians, or the left's political enemies, which they're doing now at a level that nobody can believe even possible. Third, we will totally reform FISA courts which are so corrupt that the judges seemingly do not care when they are lied to in warrant applications. So many judges have seen so many applications that they know were wrong, or at least they must have known. They do nothing about it, they're lied to. Fourth, to expose the hoaxes and abuses of power that have been tearing our country apart, we will establish a Truth and Reconciliation Commission to declassify and publish all documents on Deep State spying, censorship, and corruption, and there are plenty of them. Fifth, we will launch a major crackdown on government leakers who collude with the fake news to deliberately weave false narratives and to subvert our government and our democracy. When possible, we will press criminal charges. Sixth, we will make every Inspector General's Office independent and physically separated from the departments they oversee so they do not become the protectors of the Deep State. Seventh, I will ask Congress to establish an independent auditing system to continually monitor our intelligence agencies to ensure they are not spying on our citizens or running disinformation campaigns against the American people, or that they are not spying on someone's campaign like they spied on my campaign. Eighth, we will continue the effort launched by the Trump administration to move parts of the sprawling federal bureaucracy to new locations outside the Washington Swamp. Just as I moved the Bureau of Land Management to Colorado, as many as 100,000 government positions can be moved out. And I mean immediately out of Washington to places filled with patriots who love America, and they really do love America. Ninth, I will work to ban federal bureaucrats from taking jobs at the companies they deal with and that they regulate. So they deal with these companies and they regulate these companies and then they want to take jobs from these companies. Doesn't work that way—such a public display cannot go on and it's taking place all the time, like with Big Pharma. Finally, I will push a constitutional amendment to impose term limits on members of Congress. This is how I will shatter the deep state and restore government that is controlled by the people and for the people. Thank you very much.
    0 Reacties 2 aandelen 2K Views
  • …ANTARCTICA THE SECRET LAND, FLAT EARTH KUBRICK,
    5TH DIMENSION & FREE ENERGY?

    I'm not so sure about the "we are beyond #Antarctica" claims...
    but I am sure the earth is FLAT, and #Criminals prevent mankind from freely exploring this earth.... INCLUDING ANTARCTICA!

    YOU have as much right to explore Antarctica as does ANY OTHER HUMAN BEING!
    Yet the military men of EVERY COUNTRY ON EARTH will either kill you or cage you if you try! This is CRIMINAL!

    These scumbags have no more rights to explore Antarctica THAN YOU DO!
    YOU are within a PRISON!

    Your PRISON is everything NORTH OF THE 60th parallel
    EVERYTHING SOUTH OF THE 60th parallel is "OFF LIMITS" to all of mankind

    because of a few criminals who want it to remain a secret place, unknown to YOU!

    https://old.bitchute.com/video/Tm3cyeEkhSqt/
    …ANTARCTICA THE SECRET LAND, FLAT EARTH KUBRICK, 5TH DIMENSION & FREE ENERGY? I'm not so sure about the "we are beyond #Antarctica" claims... but I am sure the earth is FLAT, and #Criminals prevent mankind from freely exploring this earth.... INCLUDING ANTARCTICA! YOU have as much right to explore Antarctica as does ANY OTHER HUMAN BEING! Yet the military men of EVERY COUNTRY ON EARTH will either kill you or cage you if you try! This is CRIMINAL! These scumbags have no more rights to explore Antarctica THAN YOU DO! YOU are within a PRISON! Your PRISON is everything NORTH OF THE 60th parallel EVERYTHING SOUTH OF THE 60th parallel is "OFF LIMITS" to all of mankind because of a few criminals who want it to remain a secret place, unknown to YOU! https://old.bitchute.com/video/Tm3cyeEkhSqt/
    OLD.BITCHUTE.COM
    …antarctica the secret land, flat earth kubrick, 5th dimension & free energy?
    If you enjoyed today's video, if you feel you got something from it, there are ways to support this channel. And I thank all those that do. https://ko-fi.com/ceylon please buy me a coffee. Bitcoin: bc1qhxsc2phc6y0fch662xxfauhlddmzhxdj3pfy94 Pirate:…
    0 Reacties 0 aandelen 833 Views

  • 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
    BARRYZALMA.SUBSTACK.COM
    Subscribe to Excellence in Claims Handling
    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.
    0 Reacties 0 aandelen 1K Views
  • https://thewashingtonstandard.com/its-war-iranian-leaders-vow-revenge-with-no-limits-after-israel-bombs-iran/
    https://thewashingtonstandard.com/its-war-iranian-leaders-vow-revenge-with-no-limits-after-israel-bombs-iran/
    THEWASHINGTONSTANDARD.COM
    It’s War! Iranian Leaders Vow Revenge With “No Limits” After Israel Bombs Iran - The Washington Standard
    Things are about to get very interesting in the Middle East. The Israeli strike on Iran that we have been anticipating has finally happened, and now Iran is warning that there will be “no limits” in how it responds to that attack. In other words, we are on the brink ...
    0 Reacties 0 aandelen 152 Views
  • https://historyreviewed.best/index.php/canada-discrimination-against-whites-with-taxpayers-money-university-limits-whites-instills-quotas-limiting-whites-from-employment-in-education/
    https://historyreviewed.best/index.php/canada-discrimination-against-whites-with-taxpayers-money-university-limits-whites-instills-quotas-limiting-whites-from-employment-in-education/
    HISTORYREVIEWED.BEST
    CANADA: DISCRIMINATION AGAINST WHITES: With Taxpayers Money University Limits Whites & Instills Quotas Limiting Whites From Employment In Education
    “Straight, white, ‘privileged’ men won’t be warmly welcomed as MD candidates at Toronto Metropolitan University (formerly Ryerson), as only a quarter of seats will be open to their kind." Brad…
    0 Reacties 0 aandelen 392 Views
  • Farmers war with Quebec separatists over supply management bill!
    Members of the beef and cattle sector were ‘disheartened’ after the Trudeau government and Bloc Québécois rallied on Parliament Hill this month to support Bill C-282, which sets prices and limits the imports of dairy, poultry and eggs.
    #NoMoreLiberalsAndNDP
    #SayingTheQuietPartOutLoud
    #resigntrudeau
    #JustSayNoMore
    https://www.rebelnews.com/farmers_quebec_separatists_supply_management_bill
    Farmers war with Quebec separatists over supply management bill! Members of the beef and cattle sector were ‘disheartened’ after the Trudeau government and Bloc Québécois rallied on Parliament Hill this month to support Bill C-282, which sets prices and limits the imports of dairy, poultry and eggs. 🇨đŸ‡Ļ #NoMoreLiberalsAndNDP 🇨đŸ‡Ļ 🇨đŸ‡Ļ #SayingTheQuietPartOutLoud 🇨đŸ‡Ļ 🇨đŸ‡Ļ #resigntrudeau 🇨đŸ‡Ļ 🇨đŸ‡Ļ #JustSayNoMore 🇨đŸ‡Ļ https://www.rebelnews.com/farmers_quebec_separatists_supply_management_bill
    WWW.REBELNEWS.COM
    Farmers war with Quebec separatists over supply management bill
    Members of the beef and cattle sector were ‘disheartened’ after the Trudeau government and Bloc Québécois rallied on Parliament Hill this month to support Bill C-282, which sets prices and limits the imports of dairy, poultry and eggs.
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  • I've got news for all of you who still think executions have been taking place at GITMO.

    The Posse Comitatus Act is a United States federal law (18 U.S.C. § 1385, original at 20 Stat. 152) signed on June 18, 1878, by President Rutherford B. Hayes that limits the powers of the federal government in the use of federal military personnel to enforce domestic policies within the United States.

    P.S. This means you who believe this are all gullible MORONS! Go get a new tinfoil hat & wipe the bullshit drool from your lips. Meanwhile, I've got some oceanfront property for sale in South Dakota if you are interested.
    https://imgflip.com/i/962dr8
    I've got news for all of you who still think executions have been taking place at GITMO. The Posse Comitatus Act is a United States federal law (18 U.S.C. § 1385, original at 20 Stat. 152) signed on June 18, 1878, by President Rutherford B. Hayes that limits the powers of the federal government in the use of federal military personnel to enforce domestic policies within the United States. P.S. This means you who believe this are all gullible MORONS! Go get a new tinfoil hat & wipe the bullshit drool from your lips. Meanwhile, I've got some oceanfront property for sale in South Dakota if you are interested. https://imgflip.com/i/962dr8
    Like
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    0 Reacties 1 aandelen 715 Views
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