EVERY AMERICAN should know this information! And EVERY AMERICAN should also be actively dismantling this ABOMINATION every single day! This is quite possibly the # of the beast! YOUR Social Security Number! You have been made into a #Slave... BEFORE YOU WERE EVEN BORN! Edward Mandell House had this to say in a private meeting with President Woodrow Wilson: “[Very] soon, every American will be required to register their biological property in a national system designed to keep track of the people and that will operate under the ancient system of pledging. By such methodology, we can compel people to submit to our agenda, which will effect our security as a chargeback for our fiat paper currency. Every American will be forced to register or suffer being unable to work and earn a living. They will be our chattel, and we will hold the security interest over them forever, by operation of the law merchant under the scheme of secured transactions. Americans, by unknowingly or unwittingly delivering the bills of lading to us will be rendered bankrupt and insolvent, forever to remain economic slaves through taxation, secured by their pledges. They will be stripped of their rights and given a commercial value designed to make us a profit and they will be none the wiser, for not one man in a million could ever figure our plans and, if by accident one or two should figure it out, we have in our arsenal plausible deniability. After all, this is the only logical way to fund government, by floating liens and debt to the registrants in the form of benefits and privileges. This will inevitably reap to us huge profits beyond our wildest expectations and leave every American a contributor to this fraud which we will call “Social Insurance.” Without realizing it, every American will insure us for any loss we may incur and in this manner, every American will unknowingly be our servant, however begrudgingly. The people will become helpless and without any hope for their redemption and, we will employ the high office of the President of our dummy corporation to foment this plot against America.” https://historyheist.com/glossary/house-edward-mandell/

USAA Punished for it Claims Handling Punitive Damages Should be Awarded With Caution and Within Narrow Limits Read the full article at https://www.linkedin.com/pulse/usaa-punished-claims-handling-barry-zalma-esq-cfe-nbp2c, see the full video at and at and at https://zalma.com/blog plus more than 4950 posts. Posted on December 19, 2024 by Barry Zalma DISPUTE OVER HURRICANE DAMAGES RESULTS IN MAJOR PUNITIVE DAMAGES FOR BAD FAITH Although he Mississippi Supreme Court recognized the need to only award punitive damages with caution and within narrow limits, it did not limit its award in accordance with that maxim. After almost 19 years of litigation the last appeal resolved the various disputes. FACTS Hurricane Katrina destroyed Paul and Sylvia Minor’s home on August 29, 2005. The Minors had a homeowner’s insurance policy with United Services Automobile Association (USAA). The USAA policy covered damage caused by wind but excluded damage caused by storm surge or flood. The Minors reported their loss with USAA, which resulted in a years-long coverage dispute. USAA ultimately issued payments for damage it concluded was caused by wind but not for damage it concluded was caused by storm surge or flood. The Minors maintained that they suffered a total loss caused by wind and demanded that USAA pay the policy limits. The case proceeded to trial in 2013, and the jury awarded the Minors $1,547,293.37 in compensatory damages. In United Services Automobile Association v. Estate Of Sylvia F. Minor, Kathryn Minor and Stephen Minor, No. 2023-CA-00049-SCT, Supreme Court of Mississippi, En Banc (December 5, 2024) resolved the bad faith claims. The issue was ultimately presented to a jury. The jury awarded the Minors $10,000,000 in punitive damages and $457,858.89 in extra-contractual damages (solely attorneys’ fees). USAA appealed, raising several assignments of error. Trial To establish its bad faith claim, the Minor Estate introduced various USAA documents, including (1) portions of the USAA underwriting file; (2) the confidential email regarding (a) the engineer’s March 2006 findings and (b) Bergstrom’s conclusion that USAA would be responsible for paying for all the windows and the contents in rooms with windows; and (3) USAA’s letter to the Minors in June 2006 indicating the majority of damage was due to flooding. Punitive Damages Punitive damages are considered an ‘extraordinary remedy’ and should be awarded ‘with caution and within narrow limits.'” The Supreme Court found that the evidence presented at trial demonstrates a type of conduct for which punitive damages were designed. The Minor Estate provided sufficient proof that USAA acted in bad faith, with complete disregard for the Estate’s rights. Whether The $10 Million Punitive Damages Award Should Be Reversed Or, Alternatively, Reduced. USAA alternatively argues that the $10 million verdict should be reduced because it claims that the damages award is a 22:1 ratio and therefore unconstitutionally disproportionate to the extra-contractual damages awarded ($457,858.89). USAA relies on State Farm Mutual Auto Insurance Co. v. Campbell, 538 U.S. 408, 425, 123 S.Ct. 1513, 1524, 155 L.Ed.2d 585 (2003), which states that “[s]ingle-digit multipliers are more likely to comport with due process.” USAA argued that a 1:1 ratio should apply to the damages award here. The Supreme Court found that punitive damages is less than seven times the amount of compensatory damages, which it concluded clearly falls within the guideline provided in Campbell. A punitive damages award not only serves as a deterrent, it also compensates the plaintiff for its public service in bringing the action. The Supreme Court found the trial court’s decision to force the Minor Estate to use nearly half of its award to pay attorneys’ fees does not adequately compensate the Estate for bringing this action against USAA for its bad faith conduct in handling the Minors’ insurance claim from 2005. Therefore, the Supreme Court concluded that the trial court erred by denying the Estate’s post-trial motion for attorneys’ fees. CONCLUSION In sum, the trial judge did not err as a matter of law by submitting the issue of punitive damages to jury, and the $10 million award of punitive damages is not unconstitutionally disproportionate. The Supreme Court affirmed the jury verdict awarding the Minor Estate $10 million in punitive damages and $457,858.89 in extra-contractual damages as to attorneys’ fees and reverse the judgment of the trial court and render attorneys’ fees on behalf of the Estate in the amount of $4,500,000, plus post-judgment interest at an annual rate of 4 percent from October 3, 2022, the date of judgment, until paid. ZALMA OPINION This case that dragged on through the courts of Mississippi for 19 years and resulted in compensatory damages based upon an interpretation finding coverage for the estate and that the insurer’s conduct was so egregious that the estate was entitled to tort damages plus punitive damages many times more than the compensatory damages. The Supreme Court astonishingly concluded that punitive damages were not limited to punishing the insurer but were payment to the estate for its action on behalf of everyone in the state of Mississippi and that they should not be required to pay their lawyers but that payment should come from the insurer as part of its punishment. The Supreme Court ignored the fact that as a result the estate must pay income taxes on the punishment damages since they are not designed to make the insured whole and punished each member and insured of USAA. In my opinion it’s time the courts of the USA do away with the tort of bad faith to avoid excessive judgments and allow contract disputes to be enlarged into a major amount of punishment for an insurer who rejected a claim based on interpretation of contract terms and the facts of a loss, like this case. In that regard see my book, It’s Time to Abolish The Tort of Bad Faith Available as a paperback here. Available as a Kindle book here. (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

Inadequate Litigant’s Cases Dismissed Plaintiff, by her Litigation Appears to Establish the Report for a Mental Health Evaluation Was Appropriate Read the full article at https://lnkd.in/gECRyZ-f, see the full video at https://lnkd.in/gs_4Bby9 and at https://lnkd.in/g67dDK8q, and https://zalma.com/blog plus more than 4950 posts. Post 4950 In Samreen Riaz v. State Of California, et al., F087504, California Court of Appeals, Fifth District (December 2, 2024) the California Court of Appeals found itself asked to resolve suits against an individual and the state of California from an inadequate but excessively litigious plaintiff. FACTS Samreen Riaz was a licensed dentist – she lost her license to practice because of the facts underlying this case. According to her, there is an elaborate conspiracy to harass, stalk, threaten, and ultimately prevent her from testifying in a separate “whistleblower” case involving “OSHA and HIPPA Violations” at a medical facility. Riaz sued raising numerous claims against numerous individuals and government entities. The opposing parties challenged the complaint’s viability through demurrer and anti-SLAPP proceedings. The trial court sustained the demurrers and granted the anti-SLAPP motion, leaving Riaz with no viable claim. Riaz appealed. BACKGROUND The facts underlying this case involve four discrete events. First: Riaz sued a medical facility and suffered an alleged eye injury while attempting to testify in that case. Second: She sought treatment for that eye injury but was refused service and then sued that doctor in small claims court. Third: That doctor reported Riaz to the Dental Board of California which, in turn, initiated mental health competence proceedings against Riaz. Fourth: Riaz’s license to practice dentistry was revoked, and she filed the complaint at issue in this case. Initial Lawsuit Against Medical Facility Acting as a “whistleblower,” Riaz “disclosed … OSHA, Hippa, recruited patient, potential insurance fraud and anti-competent activities in the market” at a medical facility. After filing a lawsuit on that basis, Riaz claimed she suffered “organized harassment,” culminating in “permanent eye damage” after a sheriff-department employee pointed a finger in her face while attempting to enter the courthouse in her “whistleblower” case. Visiting Doctor for Eye Injury Riaz visited Dr. Cantrell to treat an eye injury. She claimed Cantrell became combative, refused to answer Riaz’s questions, and declined to treat Riaz. The next day, Riaz filed a complaint with the Medical Board of California. Several days later, she filed a small claims case against Cantrell, essentially alleging discrimination, negligence, and retaliation. A small claims judgment was eventually entered in Cantrell’s favor. Report to Dental Board Cantrell reported Riaz to the Dental Board. The Dental Board issued an order to Riaz to comply with a mental health examination “to evaluate her fitness to practice safely ….” (See Bus. &Prof. Code, § 820.) Riaz failed to comply with the order. Since Riaz continued to disobey the order, her license to practice dentistry was ultimately revoked. Instant Complaint and Judgment Riaz sued Cantrell, various government entities, and several individuals working for those entities (collectively, the State). The complaint alleged an elaborate conspiracy among all the defendants to injure Riaz, to intimidate her to prevent her from testifying, and to retaliate against her for the “whistleblower” case. The trial court sustained the demurrers and granted the anti-SLAPP motion resulting in total dismissal. DISCUSSION Did the trial court err in granting the anti-SLAPP motion? Did it err in sustaining the demurrers? The California Court of Appeals concluded the trial court did not err. Anti-SLAPP Motion In the anti-SLAPP motion, Cantrell argued his furnishing information to the Dental Board was protected activity and defeated claims “for discrimination, fraud, defamation, retaliation[,] and intentional infliction of emotional distress[.]” In opposition to the anti-SLAPP motion, Riaz claimed again Cantrell “made inaccurate, knowingly misleading statements to the [D]ental [B]oard to defame and harm [Riaz] based on disclosing patient information.” The trial court concluded furnishing those documents to the board constituted protected activity. ANALYSIS Litigation of an anti-SLAPP motion involves a two-step process. First, the moving defendant bears the burden of establishing that the challenged allegations or claims that arise from protected activity in which the defendant has engaged. Second, for each claim that does arise from protected activity, the plaintiff must show the claim has at least minimal merit. If the plaintiff cannot make this showing, the court will, and did, strike the claim. If there is no merit, the claim is stricken. The Court of Appeals noted that Riaz failed to adduce any evidence-including exhibits, declarations, judicial notice, and testimony-to substantiate her allegation Cantrell reported her to the Dental Board for retribution. She failed to adduce admissible evidence on the point. DEMURRERS Both Cantrell and the State filed demurrers to Riaz’s complaint.. Additional Background A small claims plaintiff is collaterally estopped from relitigating the same issue in superior court where the record is sufficiently clear to determine that the issue was litigated and decided against plaintiff in the small claims action. Governmental immunity is an affirmative defense properly raised by demurrer. Government Code section 821.6 immunizes public employees from liability for ‘instituting or prosecuting any judicial or administrative proceeding’ within the scope of their employment, even if the employees act ‘maliciously and without probable cause. Riaz alleged her claims arose in July 2022. Her written government claim was submitted in April 2023, more than six months later. Accordingly, the claims were barred, at least insofar as they stemmed from the section 820 order. CONCLUSION AND SUMMARY Riaz failed to allege colorable claims against either Cantrell or the State. The potential claims against Cantrell were either tried and resolved against her in small claims court or dismissed pursuant to the anti-SLAPP statute. The potential claims against the State were either barred for failure to timely present them under the Government Claims Act, or the State was immune under Government Code sections 821.6, 818.4, and 821.2. ZALMA OPINION It is axiomatic that a person who represents himself has a fool for a client. The litigation history, the multiple actions, and the lack of consistency and evidence, establish that Dr. Cantrell was correct when he advised the Dental Board that a mental health examination to evaluate her fitness to practice safely…” was correct. She refused to fulfill her obligation to the Dental Board to be evaluated because she was concerned she would not pass. This case is an abuse of Doctor Cantrell and the state and should have resulted in serious sanctions. (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

Radioactive Material Missing in New Jersey The U.S. Nuclear Regulatory Commission (NRC) has officially issued an urgent notification: radioactive material described as “less than Category 3” but possibly shielded Category 4 has been lost in transit. This is not a drill, and it is not something that can be ignored. The shocking revelation came after a report submitted to the New Jersey Department of Environmental Protection (NJDEP) detailed the incident. https://amg-news.com/radioactive-material-missing-in-new-jersey-urgent-alert-from-u-s-nuclear-regulatory-commission/

Lose if You Fail to Respond to Motion for Summary Disposition INSURERS FIND FRAUDSTERS ARE OFTEN INCOMPETENT Post 4943 Read the full article at https://www.linkedin.com/pulse/lose-you-fail-respond-motion-summary-disposition-zalma-esq-cfe-rhstc, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts. 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) the Court of Appeals resolved the dispute. In a consolidated first-party and third-party no-fault action, plaintiff appealed from two orders granting summary disposition in favor of defendants, including the fraud of the plaintiff. FACTUAL BACKGROUND After a motor vehicle accident involving plaintiff and Pugh. Plaintiff alleged 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 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. Shortly after Pugh filed her motion, Citizens filed its own motion arguing that plaintiff made material misrepresentations to Citizens regarding the extent of his injuries, which rendered him ineligible for benefits under the statute. The trial court concluded that plaintiff failed to establish that he sustained a serious impairment of body function and therefore summary disposition in favor of Pugh was appropriate. With regard to Citizens’ motion, the trial court found “that absolutely no genuine issue of material fact exists as to whether Plaintiff knowingly made numerous materially false statements in his claims for PIP benefits relative to his alleged injuries and physical restrictions” arising out of the car accident. THRESHOLD INJURY Plaintiff argued that the trial court erred by finding that there was no genuine issue of material fact regarding whether plaintiff met the serious-impairment threshold. However, plaintiff’s failure to respond to the motion for summary disposition made it impossible for him to support his argument. The Plaintiff tried to use the defendants evidence as support against the motions. The attempt failed. The objectively manifested requirement means that plaintiffs must introduce evidence that generally requires medical testimony. Pugh presented objective medical records indicating that there was no physical basis for plaintiff’s subjective complaints of pain. Plaintiff’s deposition testimony only set forth mere subjective complaints of pain. Because plaintiff cannot show a factual dispute as to whether he suffered an objectively manifested impairment, he failed to satisfy the threshold serious-impairment requirement. FRAUDULENT INSURANCE ACT A person who presents or causes to be presented an oral or written statement, including computer-generated information, as part of or in support of a claim for payment or another benefit knowing that the statement contains false information concerning a fact or thing material to the claim commits a fraudulent insurance act that is subject to the penalties imposed by statute. 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 to the insurer or the state, 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. As to both motions for summary disposition, plaintiff failed to show that any genuine issue of material facts exists. Accordingly, the trial court did not err by granting summary disposition in favor of defendants. ZALMA OPINION As I get older the competence of those who attempt to defraud insurers gets less and less competent. Kallco is an example of the lack of competence. He claimed all kinds of injuries and inability to work or play with his children and, when faced with a competent defense, he ignored the motions, failed to respond, and when he lost he appealed claiming the motions against him gave enough evidence to raise a issue of fact. What a waste of the court’s time and I must ask why, with such convincing evidence, no criminal charges were brought. (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 Sorry about the delay in posting. I’m recovering from pneumonia and spending most of the last week in bed with pills, Kleenex, coughing and sleep which I couldn’t get in the hospital. Should be act in shape next week but doctors make no promises.

Zalma's Insurance Fraud Letter - December 1, 2024 ZIFL Volume 28 No. 22 Post 4939 Read the full article at Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdfand at https://zalma.com/blog. 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 https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf Zalma’s Insurance Fraud Letter (ZIFL) continues its 28th year of publication dedicated to those involved in reducing the effect of insurance fraud. ZIFL is published 24 times a year by ClaimSchool and is written by Barry Zalma. It is provided FREE to anyone who visits the site at http://zalma.com/zalmas-insurance-fraud-letter-2/ This issue contains the following articles about insurance fraud: The EUO is a Material Condition Precedent A Key Tool in the Effort to Reduce Fraud Claim Properly Denied for Refusal to Testify at EUO I spoke recently at the Conference of the Southern California Fraud Investigators Association on the Examination Under Oath as a tool to help insureds prove their losses and what happens when an insured fails or refuses to testify. This case emphasizes the purpose of my talk. Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf Thanksgiving Wishes from the Zalma Family My family and I have much to be thankful for this year. My first born daughter, Stephanie Zalma, continues to care for my wife 24 hours a day 7 days a week with love and patience as Thea continues as Nana to our two grandchildren and the loving mother of our three children. After receiving a new Aortic Heart Valve I am personally in good health, walking about 25 miles a week. Exercising my, apparently unusual mode of retirement, I work only six to eight hours a day doing what I love the most, writing about insurance, insurance claims, insurance law and acting as an insurance claims consultant and expert witness. Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf More McClenny Moseley & Associates Issues This is ZIFL’s thirty eighth installment of the saga of McClenny, Moseley & Associates and its problems with the federal courts in the State of Louisiana and what appears to be an effort to profit from what some Magistrate and District judges may be criminal to profit from insurance claims relating to hurricane damage to the public of the state of Louisiana. Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf Ethical Behavior & Insurance Insurance, from the time of its first agreement to the present day has always been a business requiring ethical behavior between the insurer and the insured and between the insured and the insurer. The concept of ethical behavior refers to well-founded standards of right and wrong that prescribe what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues, all of which are essential to the lawyer. Ethics refers to those standards that impose the reasonable obligations to refrain from murder, rape, theft, assault, slander, and fraud. Ethical standards also include those that imply virtues of honesty, compassion, and loyalty. There are rights presumed to exist such as those described in the Declaration of Independence submitted to King George of England in 1776 that held: We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of happiness. The unalienable rights also include the right to life, the right to freedom from injury, and the right to liberty. Such standards are adequate standards of ethics because they are supported by consistent and well-founded reasons. Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf Health Insurance Fraud Convictions Michigan Woman Convicted of $1.4M Health Care Kickback Scheme Mary Smettler-Bolton, 71, of Oakland County, Michigan was convicted November 22, 2024 for her role in a conspiracy to defraud the United States and receive illegal health care kickbacks. According to court documents and evidence presented at trial, Mary referred Medicare beneficiaries to several Metro Detroit home health companies in exchange for hundreds of thousands of dollars in kickbacks paid by the owners and operators of the home health companies. Over the course of four years, she and her co-conspirators caused over $1.4 million of loss to Medicare. Smettler-Bolton was convicted of one count of conspiracy to defraud the United States and receive illegal health care kickbacks and one count of violating the federal Anti-Kickback Statute. She is scheduled to be sentenced on March 3, 2025, and faces a maximum penalty of five years in prison on the conspiracy count and a maximum penalty of 10 years in prison on the kickback count. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors. Read the full article about dozens more convictions at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf Convictions of Other Than Health Insurance Fraud Creative Fraudster Guilty of $229K Insurance Fraud Schemes Justin Mack, a native of Buffalo, New York, and a resident of Cleveland, Ohio, was sentenced on November 25, 2024 in the Cuyahoga County Court of Common Pleas. Mack, an Ohio man was sentenced to five years in prison and ordered to pay restitution for filing 24 fraudulent claims with multiple insurance companies, totaling more than $229,000. An extensive investigation uncovered Mack’s pattern of submitting altered documentation, falsified claims, and using other people’s identities to fraudulently secure payouts from multiple insurance companies. Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf The Examination Under Oath Is Not Part of a Judicial Process Although the EUO is a formal proceeding it is not part of a judicial process nor is it subject to the rules set out by codes of civil procedure. There is no right to object to questions and never a judge present to rule on the objections. The testimony at the EUO is required to be presented in accordance with the obligation imposed on an insured to deal fairly and in good faith with the insurer. Read the full article at https://zalma.com/blog/wp-content/uploads/2024/12/ZIFL-12-01-2024.pdf Barry Zalma Barry Zalma, Inc., 4441 Sepulveda Boulevard, CULVER CITY CA 90230-4847, 310-390-4455. Subscribe to Excellence in Claims Handling at https://barryzalma.substack.com/welcome. Write to Mr. Zalma at [email protected]; https://www.zalma.com; https://zalma.com/blog. He publishes daily articles at https://zalma.substack.com, Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ to consider more than 50 volumes written by Barry Zalma on insurance and insurance claims handling. Go to Zalma’s Insurance Fraud Letter at https://zalma.com/zalmas-insurance-fraud-letter-2/; Go to X @bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ and GTTR at https://gettr.com/@zalma

EUO is a Material Condition Precedent Claim Properly Denied for Refusal to Testify at EUO Post 4936 Read the full article at https://www.linkedin.com/pulse/euo-material-condition-precedent-barry-zalma-esq-cfe-exccc, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts. See the full video at and at Erin Hughes appealed from the grant of summary judgment in favor of defendant and respondent Farmers Insurance Exchange (Farmers) on her causes of action for breach of contract and bad faith arising after Farmers’ denial of Hughes’s property insurance claim because she refused to testify at a second examination under oath (EUO). In Erin Hughes v. Farmers Insurance Exchange, B331168, California Court of Appeals (November 8, 2024) the condition precedent was enforced. FACTUAL BACKGROUND Hughes is the owner of real property in Malibu (the property). In December 2020, Hughes obtained an insurance policy to cover the property for fire loss through the California FAIR Plan Association (FAIR Plan). Also in December 2020, Hughes obtained a homeowner’s insurance policy from Farmers to cover perils other than fire, including losses due to theft (the policy). One month later, in January 2021, the property sustained significant fire damage. Hughes contacted Farmers, which advised her that fire loss was not covered by her Farmers policy, and she would have to pursue any such claim through her FAIR Plan policy. Unhappy, on January 21, 2021, Hughes tendered a theft claim under the Farmers policy, asserting in excess of $2 million worth of personal property was stolen from the property. Farmers ultimately denied the claim on January 5, 2022, on the ground that Hughes failed to cooperate with Farmers’ investigation, including by failing to participate in a second examination under oath as required by the policy. Hughes’s Complaint Against Farmers One week after the denial of her claim, Hughes sued Farmers and alleged Farmers demanded “duplicative, onerous and/or unnecessary” documentation of stolen items. Further, she alleged Farmers subjected her to “two confrontational, accusatory and grueling examinations under oath.” Hughes alleged her second examination under oath had been “suspended due to [her] medical condition,” but Farmers disregarded her condition and demanded a third examination. Farmers’ Motion for Summary Judgment Farmers moved for summary judgment contending it properly denied Hughes’s theft claim based on her failure to cooperate with Farmers’ investigation of her claim as well as her material misrepresentations in obtaining the Farmers policy. In May 2021, as part of Farmers’ theft claim investigation, Hughes participated in an examination under oath. During the examination, Hughes’s counsel informed the Farmers attorney he had just sent more than 40 additional receipts that the attorney would be receiving shortly. Recognizing they would not have time to go through the new items that day and the examination would need to continue on a future date, the Farmers attorney proposed “continu[ing] to work with one another to identify what’s missing.” In response, Hughes and her counsel agreed, with Hughes stating she would be happy to get “every single thing that you need and I’ll send it to my attorney right away.” In October 2021, a second session of the examination under oath was held regarding documentation Hughes had produced during and after the first session. Hughes appeared remotely with counsel and before any questions were asked of her, she objected to a further examination. Hughes accused the Farmers attorney of interrogating her “like a fucking criminal” and stated, “if you want to take my deposition . . . you are going to take a second deposition in court, and that’s going to be a formal deposition.” Hughes’s remote connection then cut out, and her counsel indicated she would not proceed with the examination. Farmers informed Hughes that it was denying coverage based on her failure to cooperate with Farmers’ investigation and particularly her refusal to proceed with the second examination under oath. Trial Court’s Grant of Summary Judgment and Denial of Hughes’s Continuance Request and Motion for New Trial The trial court granted summary judgment in favor of Farmers. Noting an insurer has “an absolute right” to require the insured to submit to an examination under oath “as long as the insurer exercises the right reasonably,” the court determined Hughes had not shown Farmers acted unreasonably. The court concluded summary judgment was appropriate “based solely on failure to cooperate.” DISCUSSION The trial court properly concluded there was no genuine dispute that Hughes’s failure to participate in an examination under oath constituted a material breach of the policy; accordingly, Farmers was excused from having to pay on Hughes’s claim. The right to require the insured to submit to an examination under oath concerning all proper subjects of inquiry is reasonable as a matter of law. An insured’s compliance with a policy requirement to submit to an examination under oath is a prerequisite to the right to receive benefits under the policy. Because Hughes refused to cooperate with Farmers’ investigation by participating in and completing her examination under oath, she cannot establish her own performance under the policy. Breach of Implied Covenant Claim The implied covenant of good faith and fair dealing is based on general contract law and the long-standing rule that neither party will do anything which will injure the right of the other to receive the benefits of the agreement. Hughes’s claim for bad faith fails as a matter of law. ZALMA OPINION Wildfires tend to destroy everything. That is why insurers are unwilling to write fire insurance in Malibu and other areas prone to wildfires and obtain fire insurance from the Fair Plan, an organization designed to cover uninsurable risks. Because of the destruction done by a wildfire or a dwelling fire a $2 million dollar theft loss after a fire is questionable and a good reason to take a thorough EUO. Farmers tried to do so and Hughes refused without reason after admitting she left open much investigation elements at the agreed conclusion of the first session and an agreement to a second only to refuse. (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

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.

Chutzpah – STOLI Fraudster Claims Hardship Felon Seeks Release from Home Confinement in Luxury Apartment in New York City Post 4931 Read the full article at https://www.linkedin.com/pulse/chutzpah-stoli-fraudster-claims-hardship-barry-zalma-esq-cfe-8jbhc, see the full video at and at and https://zalma.com/blog plus more than 4900 posts. 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. BACKGROUND Michael Binday was sentenced to 144 months’ imprisonment after being found guilty of conspiracy to commit mail and wire fraud, as well as actual mail and wire fraud. The evidence at trial established that Binday led his codefendants in a scheme designed to procure “stranger-originated life insurance” (or “STOLI”) policies-policies on the lives of seniors for the benefit of investors who were strangers to them- by means of fraudulent applications. Binday spent the first five years of his sentence at FCI Otisville. But in September 2021, during the height of the COVID-19 Pandemic, the Bureau of Prisons released Binday to serve his sentence on home confinement. Thus, Binday has spent the last three-plus years serving his sentence in his luxury apartment on the upper westside of Manhattan. His sentence is scheduled to end on September 20, 2025. Binday filed: (1) a motion for compassionate release and (2) a motion pursuant to Rule 60(b) of the Federal Rules of Civil Procedure seeking to vacate the judgement of this Court dated May 23, 2018, denying his first petition. Michael Binday and his two codefendants, James Kergil and Mark Resnick, were found guilty of conspiracy to commit mail and wire fraud; mail fraud; and wire fraud in connection with a scheme to defraud insurance companies which the defendants purported to serve as agents. Binday led his codefendants in a scheme designed to procure “stranger-originated life insurance” (or “STOLI”) policies-policies on the lives of seniors for the benefit of investors who were strangers to them- by means of fraudulent applications. Over the course of their scheme, the defendants submitted at least 92 fraudulent applications, resulting in the issuance of 74 policies with a total face value of over $100 million. These policies generated roughly $11.7 million in commissions to the defendants. Binday was sentenced to 144 months’ imprisonment. BINDAY SURRENDERS Binday surrendered on July 1,2016, to FCI Otisville to commence his term of imprisonment and immediately filed motions for compassionate release, reversal of his convictions, and multiple other motions. On July 1, 2024, Binday-who is serving his sentence in his Manhattan apartment- filed a renewed motion for compassionate release. Binday Failed to Demonstrate Extraordinary and Compelling Circumstances As a threshold matter, it is worth emphasizing that Binday is not asking to be released from prison, but rather, to be relieved of the inconveniences associated with the rules of home confinement. He has served the last 38 months in his apartment on the upper west side of Manhattan (not at all what the Court intended when he was sentenced). How much more inconvenient it would be if he were back at Otisville- where the Court intended that he would serve his sentence. Binday’s crimes were serious. As the court explained when he was sentenced to 144 months in prison: Venality, rampant mendacity, the creation of false documents, obstruction of efforts by the victims to ascertain the truth, obstruction of regulators and the government’s efforts to learn the truth, Binday’s actions were precisely the sort of criminality that has left large segments of our society convince that all businessmen are crooks. Insurance fraud may not qualify as a crime of violence within the meaning of the federal sentencing system and that, unfortunately, is why it is all too often punished not with the severity that it deserves. As it is, Binday’s home confinement means that he is subject to far less stringent conditions than he would be otherwise. In that regard, he got more of a break than he deserves. The motion for compassionate release was denied. ZALMA OPINION STOLI fraud is a type of fraud on insurers that effects the straw buyers, usually older men and women who have no need for life insurance, is a truly venal act that deserves serious punishment. Binday stole millions from insurers, owns a luxury apartment in the Upper West Side of New York, and wants to be released from the confinement when he should have stayed in federal prison. He has abused the courts with his multiple motions and appeals and will serve out the remainder of his sentence and the DOJ and FBI should look into his current conduct since there is, in my opinion, the possibility that he is funding his attorneys fees with more 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 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

Chiropractor Disciplined for Improper Billing Chiropractor Lies to Board and Loses Right to Practice Post 4930 Read the full article at https://www.linkedin.com/pulse/chiropractor-disciplined-improper-billing-barry-zalma-esq-cfe-4qjdc, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts. This appeal arises from an attempt by the state of Illinois to impose discipline upon plaintiff Christopher D. Leone, D.C., due to certain improper activities performed as a licensed chiropractor in the state of Illinois. In Christopher D. Leone, D.C. v. The Department Of Financial And Professional Regulation, Division Of Professional Regulation; and Cecilia Abundis, in Her Official Capacity as Acting Director of the Department of Financial and Professional Regulation, No. 4-22-0753, 2024 IL App (4th) 220753-U, Court of Appeals of Illinois, Fourth District (November 6, 2024) the Court of Appeal resolved the multiple claims of the chiropractor. BACKGROUND Leone has practiced as a chiropractor since 1999 and initially practiced in the state of Washington. The matter was resolved pursuant to an informal disposition via stipulation. Leone began practicing in Illinois in 2004, and in 2010 and a consent order was issued pursuant to which Leone admitted to the allegations and was reprimanded with a $5000 fine and a requirement that he undertake 20 hours of continuing education; 10 of those hours were to focus on Medicare billing and insurance coding and another 10 on record keeping. In 2013, the United States alleged that Leone “knowingly and fraudulently” submitted Medicare claims of less than $1000 for one-on-one physical therapy services that were not provided. Following negotiation, the parties entered into a plea agreement, pursuant to which Leone pleaded guilty to the one-count information and stipulated to a factual basis for his plea. Shortly after the Medicare fraud charge was filed against Leone, the State filed a five-count complaint alleging multiple violations of the Medical Practices Act of 1987 (Act). During the litigation, Leone applied to renew his chiropractic license. One of the questions on the application asked whether he had been convicted of any criminal offense, state or federal, since July 2011; Leone answered, “No,” failing to document the Medicare fraud conviction. Attempting to explain his federal guilty plea, Leone said that he was unable to modify the language in the plea agreement, as “the time for negotiations had run out” and the plea was a “take-it-or-leave-it” proposition. Leone read the plea agreement line by line and, although he claimed it contained false information, he signed it. ALJ Report and Recommendation The Administrative Law Judge (ALJ) issued his report and recommendation, finding that, pursuant to the guilty plea in the federal case, Leone had admitted that his patients performed physical therapy on their own without supervision. Also, Leone admitted in his plea that entries in patient records indicating that they received hands-on or one-on-one physical therapy were false. Further, the guilty plea established that Leone knowingly submitted claims to Medicare for services that he did not provide. Leone had also billed private insurers numerous times under the same code as Medicare. The conviction also established that he engaged in false billing and false entries in patient records. The ALJ recommended an indefinite suspension of Leone’s license for a minimum of two years. An expert testified that chiropractors who engaged in Medicare fraud violated several tenets of chiropractic ethics. There was a pattern of overcharging for services that were not provided, false notations in patient records to support the false charges, and the submission of false claims to insurance that went on for at least five years. Leone obtained fees by fraud, deceit, or misrepresentation, and those actions fell below the professional and ethical standards required of chiropractors in Illinois. Leone’s conduct, along with his past disciplinary history, “demonstrate[d] a pattern of behavior that [was] not acceptable.” ANALYSIS It was undisputed that Leone submitted charges under billing code 97110. Leone pled guilty to submitting a false demand for payment upon the United States. In his plea, Leone admitted to billing for services that were not actually provided to his patients as claimed, “and the instruments containing the demands for payment of public money, therefore were false when they were submitted” and “were submitted to Medicare with the knowledge that he did not perform the service charged.” The guilty plea supports the conclusion that Leone knowingly and intentionally submitted claims for reimbursement for services provided under code 97110 where the services did not meet the requirements to be paid under that code. This pattern went on for approximately five years, resulting in 1324 false claims in the amount of $93,900. The Department established a violation of the Act where Leone failed to note the federal conviction on his renewal application. Discipline A review of the initial circuit court order in this matter reveals that it merely recommended that the Department consider probation as a punishment; it did not make a ruling to that effect. There was no abuse of discretion in the discipline imposed. For the reasons stated, the Court reversed the circuit court’s judgment and affirm the Director’s decision. ZALMA OPINION Leone successfully committed fraud on the United States, the state of Illinois, and the insurance industry by falsely billing services he did not provide. He pleaded guilty to one count of Federal Health Insurance fraud and then lied to the state of Illinois when he applied to renew his license. With lawyers and retained experts he delayed the sanction for years. The Court of Appeals finally resolved the multiple disputes and applied an appropriate sanction and suspension of his license. He should consider himself lucky that he was not prosecuted criminally by the state and the US Government accepted his plea. (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