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

I am Thankful Thanksgiving Wishes from the Zalma Family Post 4938 Posted on November 27, 2024 by Barry Zalma See the full video at and at hope, on this Thanksgiving weekend, that you can join my family and me remembering that it is more important to think about our blessings and those things that we have to be thankful for than to get in line for “Black Friday” to buy an inexpensive flat screen t.v. or tablet. Enjoy the holiday and your family as I will. 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. To me, I am thankful for you, my friends, clients and readers of “Zalma’s Insurance Fraud Letter,” my blog “Zalma on Insurance,” and my books and other writing including the third Edition of the ten volumes of my treatise, “Zalma on Insurance Claims” and the Fourteenth Edition of “Property Investigation Checklists.” As a first generation American I am honored to join with all Americans the ability to celebrate Thanksgiving that started when the United States was a dream and just a colony of Great Britain, to give thanks for the good things in life at least once a year. It took Abraham Lincoln, our greatest President to make it an official holiday. The Thanksgiving holiday gives me and my family the opportunity to consider the blessings we have received and to thank all who have made it possible. Please allow me this opportunity to explain to you all the things I, and my family, can continue to give thanks for: 1. I have loved my wife of almost 57 years since we first met when she was nine and I was twelve. 2. I am thankful that she still loves me and lets me make clear every day that I love her more now than I did when she ignored me when I was 12. 3. My three adult children who are successes in their own right. 4. That my three children who put up with my wife and I, and are healthy, successful, and mostly happy in what they do. 5. My almost eight-year-old granddaughter and my 22 year-old grandson live nearby, my grandson is now a successful college graduate from Puget Sound University in Washington state and working full time in I.T. 6. My clients who, for the more than 57 years have allowed me to earn a living doing what I love. I practiced law until I let my license go inactive, acting as a consultant, testifying as an expert witness and writing materials to help others provide excellence in claims services as members of the insurance profession. 7. My publishers the American Bar Association, Full Court Press, Fastcase.com, Thomson Reuters and Amazon.com. 8. My dearly departed parents and grandparents for having the good sense to leave the Ottoman Empire at the beginning of the 20th Century so we could avoid the Holocaust and I could be born American. 9. My country for giving me a place to live and work in peace and complain about it without fear. 10. The state of California, where I was born, and have lived for 82 years, for allowing me to have my home and grow my family, and the ability to pay California’s high taxes for the privilege. 11. Those of you who read what I write and gain something from it. 12. Eighty two years of mostly good health, but for a small heart attack,clogged arteries, a failed Aortic heart valve, ant the surgeons that gave me the ability to continue to work – albeit at a reduced rate. 13. Allowing me the health and ambition to avoid my cardiologist by walking every day and working on my garden and bonsai with one of my Chinese Elms in a pot for more than 49 years. 14. The hundreds of friends I have never met but with whom the Internet has allowed me to communicate in parts of the world I have never visited. 15. The wonder of the Internet that allows me to publish E-books, ZIFL and my blog instantly on line. 16. That my family can get together to express our thanks for each other and our happiness this year again without a need for anything but enjoying each other’s company and some good food. 17. That most of you who I know only by my publications can also gather with your families to express your thanks. When I enlisted in the U.S. Army in 1964, I volunteered ostensibly to avoid the draft and volunteered to serve anywhere in the world. Fortunately, the Army made assignments in alphabetical order and I was sent by the U.S. Army Intelligence Corps to Peoria, Illinois where I became a Special Agent in Charge of an office investigating people who sought security clearances. I was trained to be an investigator and enjoyed every minute of the job. Until the Army I had never seen a river without a concrete bottom only to see the mighty Mississippi as my first real river. I had never seen snow other than in the distance on mountains only to find myself shoveling the snow off the driveway in the small half-of-a-house I rented from an old couple who could not do it themselves. My investigative assignments required me to travel throughout Central Illinois from the Iowa to the Indiana borders. I stopped at court houses along the way, all of which had signs that Abraham Lincoln practiced law there. Those experiences with the courts, law enforcement officers, and court personnel probably gave me the incentive to become a lawyer. When I finished my three year enlistment I returned home, proposed marriage to the love of my life, who fortunately for me, accepted. I began the study of law at night and found my first real job where I could use the skills I learned in the Army. I was hired as a claims trainee at the Fireman’s Fund American Insurance Company who spent the time to train me to be a claims adjuster. The training was, unlike modern insurers, thorough. I was required to read a treatise on insurance and insurance claims handling. I was sent out with experienced adjusters in all types of insurance Fireman’s Fund wrote to learn as they adjusted claims, and eventually allowed to deal with the public under close supervision. Contrary to the requirements of the insurance industry at the time, Fireman’s Fund allowed me to study law at night while I worked as a full-time insurance adjuster. I was fortunate enough to work for a claims manager – Coleman T. Mobley – who did not require me to go out of state to adjust major storm claims if it interfered with my law school studies. Since I was in law school 50 weeks a year the only catastrophe storm duty I was required to work was a fire storm that burned from the San Fernando Valley to the ocean at Malibu. Because of Mr. Mobley and the Fireman’s Fund I was able to complete my studies and pass the California Bar in 1971 and be admitted to the California Bar on January 2, 1972. I took a cut in pay to get my first job as an Associate Attorney with a law firm that was willing to teach me to be a lawyer handling every kind of problem a new lawyer could face from wills, tort claims, divorce, drunk driving, trials, depositions, and dozens of orders to show cause in multiple courts around the Inland Empire of California. By doing so, when I started practicing law in 1972, I became a lawyer who could deal with any issue brought to me. I was fortunate enough to be able to move to an insurance law firm in Century City where I was assigned to a coverage lawyer who was trying to deal with over 500 active matters and, who, when I arrived, assigned 250 of the matters to me and pointed me to the firm’s library to learn what to do. At the time new technology was an IBM Selectric typewriter that could erase errors from the keyboard without the need to use white-out paint. I did legal research in the firm’s large library which, when it was inadequate for the task, I drove to the County Law Library in downtown Los Angeles to adequately research legal questions . Research in a large library took days to find support for an issue. I needed three professional legal secretaries to keep up with my dictation. Now, using modern technology, I can do the same legal research in 30 minutes on Fastcase.com, need no secretary, and can operate my consulting, writing, training and publishing businesses with no employees. In 1979 I decided it was time to be my own boss. I started a law firm called Barry Zalma, Inc. with a secretary who came from my last firm and brought an IBM Selectric typewriter with her into a small windowless office. I had obtained a line of credit from a bank that I hoped would carry us until the practice started since the only case I was sure of when I moved into my new office, was my sister’s rear-ender from which I could not, and did not, take a fee. The office was furnished with a file cabinet from my father-in-law’s dental practice and a dining room table from my wife’s grandmother who had passed away. I received my first call at 8:10 a.m. on the first day, October 1, 1979, from Alan Worboys, a claims person speaking for Certain Underwriters at Lloyd’s, London and my practice began. Alan became, and still is, a long time friend. I had nothing to do on October 3, 1979 so I wrote an article for publication. After that, I had no peace and the firm quickly grew to 9 lawyers and a staff to serve them all defending people who were insured and acting as coverage counsel for insurers who needed advice and counsel concerning interpretation of insurance contracts and how to deal with attempted fraud. I, and the lawyers who joined the firm also provided defense to insureds of our clients and defense of suits against the insurers for tort, including the tort of bad faith. I was more successful than I ever expected. I, whose experience was limited to Los Angeles County and Central Illinois, found a need to travel to Taipei, Taiwan and London, England on behalf of my clients. I worked, as I had learned from my father who survived the Depression, 16 hours a day, six or seven days a week. When I became 75 years old my firm had been reduced back to a sole practice and I decided it was time to stop practicing law and become a consultant and fulfill my childhood dream to be an author. I am a very lucky and happy man. I do work that I love. I fulfilled my childhood dreams. I Live in a home I have owned for more than 49 years that my wife and I adapted and increased as children were born to meet our needs. I have the love of my life with me and look forward to celebrating our 57th wedding anniversary next month. I am honored that my eldest daughter has come back to live with us and care for my wife and I who are not able to do everything we used to do. I have three wonderful children, two grandchildren and all live close. My son, and his business shares my office building and has time to visit with me as allowed by his busy schedule. (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 This is a long article so go to https://www.linkedin.com/pulse/i-am-thankful-barry-zalma-esq-cfe-bzysc, to read the full article.

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

Insurer Properly Sanctioned for Failure to Obey Court Order It is Never Proper to Fail to Comply With Court Order Post 4937 Read the full article at https://www.linkedin.com/pulse/insurer-properly-sanctioned-failure-obey-court-order-barry-vefvc, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts. Insurer Privilege Underwriters took its name too far trying to obtain privileges from the Arkansas Court of Appeals to which it was not entitled and acted contumaciously by disobeying the Circuit Court’s discovery order. In Privilege Underwriters Reciprocal Exchange v. Brandon Adams, No. CV-23-474, 2024 Ark.App. 571, Court of Appeals of Arkansas, Division I (November 20, 2024) the circuit court granted appellee Brandon Adams’s motion to enforce court order and motion for sanctions, imposed a “sanction fee in the amount of $5,000” against appellant Privilege Underwriters Reciprocal Exchange (“Privilege”), and awarded Adams $2,500 in attorneys’ fees and costs under Arkansas Rule of Civil Procedure 37; denied Privilege’s motion for summary judgment; and denied Privilege’s motion for protective order, which sought to bar Adams from taking any depositions. FACTS In an insurance-coverage action in which Adams sued Privilege, his insurer, for failing to provide him a defense in a lawsuit filed against Adams and several other individuals and entities. Privilege answered Adams’s coverage complaint denying that it owed Adams a duty to defend the lawsuit and asserting a number of the subject policies’ exclusions as affirmative defenses to coverage. Adams served written discovery on Privilege. Privilege responded with objections and inadequate responses to Adams’s discovery requests. Adams moved to compel Privilege to respond and produce documents and the Court of Appeals ordered Privilege respond and to pay Adams’s attorneys’ fees and costs in the amount of $2,000. Privilege produced its supplemental interrogatory answers and supplemental privilege log on March 2, 2022 but did not comply with the circuit court’s discovery order. Contrary to the court’s order Privilege refused to amend its privilege log, provide full and complete answers to Adams’s interrogatories, or produce any witnesses for deposition, and instead, Privilege moved for summary judgment. Adams then filed his “Motion to Enforce Court Order and Motion for Sanctions and Incorporated Brief” on April 25, 2022. On December 20, 2022, the circuit court held a hearing on Adams’s motion for sanctions and Privilege’s motions for summary judgment and for protective order. The circuit court announced that it would sanction Privilege for its failure to comply with the circuit court’s February 2022 discovery order. From the bench, the circuit court made specific findings that Privilege had failed to comply with the provisions of that order requiring Privilege to amend its privilege log to provide sufficient information to allow the circuit court and Adams to evaluate Privilege’s claims of attorney-client privilege and work-product protection and to fully answer Adams’s interrogatories. TO ESTABLISH CONTEMPT Generally, in order to establish contempt, there must be willful disobedience of a valid order of a court. Contempt is a matter between the court and the litigant, and not between the two opposing litigants. Before one can be held in contempt for violating the court’s order, the order must be definite in its terms, clear as to what duties it imposes, and express in its commands. Contempt is divided into criminal contempt and civil contempt. The standard of review on appeal depends on whether the contempt sanction was civil or criminal in nature. The circuit court imposed a fine and fees that were to be paid to Adams. A contempt fine for willful disobedience that is payable to the complainant is remedial and therefore constitutes a fine for civil contempt. Privilege refused to comply with a valid discovery order from the circuit court because Privilege disputed Adams’s entitlement to the discovery underlying that order. Instead, Privilege moved for summary judgment, attempting to render moot that prior discovery order. The circuit court rightly held Privilege in contempt for its willful disobedience of the circuit court’s February 2022 discovery order and imposed a fine of $5,000. Once the February 2022 discovery order was entered, Privilege was required to comply with that order, not question the propriety of that order or when Privilege should comply with it. The circuit court was unequivocal in finding at the December 2022 hearing that it was sanctioning Privilege for its violation of the February 2022 discovery order. The circuit court then went on to explain that Privilege had disobeyed its February 2022 order by failing to provide contact information for the witnesses identified in response to Interrogatory No. 1 and by failing to provide a privilege log with sufficient information to allow the circuit court and Adams to evaluate the claim of attorney-client privilege and work-product protection. Thus, the Court of Appeals held that the circuit court did not clearly err in holding Privilege in contempt. The circuit court had ample authority to use its contempt powers to enforce its February 2022 discovery order. ZALMA OPINION This order must be more than embarrassing to Privilege and to the insurance industry. Parties to litigation are not entitled to refuse to fulfill an order of the court. Regardless of the name of the insurer it had no special privileges and must fulfill the order to the letter and pay the sanctions including the extra sanctions placed by the Court of Appeals. (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

Requiring an Insurer to Waive its Right to Subrogation is a Valid & Enforceable Contract Waiver of Subrogation Applies in Marine Insurance Policy Post 4938 Read the full article at https://www.linkedin.com/pulse/requiring-insurer-waive-its-right-subrogation-valid-zalma-esq-cfe-gkn3c/, see the full video at and at and at https://zalma.com/blog. Competing motions for summary judgment were presented to the USDC for the Eastern District of Louisiana in a limitation-of-liability action arising from the listing and capsizing of the liftboat RAM XVIII. The motions present the principal question whether Fieldwood (charterer of the liftboat) must defend and indemnify Aries (owner of the liftboat) and U.S. Specialty (Aries’s insurer) under a master time charter agreement from the personal-injury claims brought by employees of Fluid Crane & Construction, Inc. and United Fire and Safety, LLC (Fieldwood’s subcontractors) who were aboard the RAM XVIII when it capsized. Fieldwood moved for partial summary judgment enforcing waivers of subrogation in the master time charter agreement and the relevant U.S. Specialty insurance policy. In The Matter Of Aries Marine Corporation, et al., Civil Action Nos. 19-10850, 19-13138, United States District Court, E.D. Louisiana (November 20, 2024) the USDC resolved the disputes. BACKGROUND The USDC resolved a five-year-old limitation-of-liability action that arose from the listing and capsizing of the liftboat RAM XVIII in the Gulf of Mexico. Aries chartered the RAM XVIII to Fieldwood under a master time charter agreement (the “Time Charter”) in relation to work being performed on one of Fieldwood’s offshore platforms. Under those Master Services Contracts, Fluid Crane and United Fire sent employees to work on Fieldwood’s platform; those employees were aboard the RAM XVIII when it capsized. U.S. Specialty, for its part, underwrote an insurance policy (the “Policy”) that provided Aries with certain coverages in effect when the RAM XVIII capsized. Six employees of Fluid Crane and one employee of United Fire-all of whom were aboard the RAM XVIII when it capsized-brought personal injury claims against Aries. The motions before the Court present the principal question whether Fieldwood must defend and indemnify Aries and U.S. Specialty from those personal-injury claims. THE TIME CHARTER Section 10 features a waiver-of-subrogation provision mandating that “[u]nderwriters of all policies of insurance required [by Section 10] shall waive their rights of subrogation against the Charterer Group,” which includes Fieldwood. THE POLICY The Policy provides coverage to Aries for protection and indemnity, including coverage for personal-injury liability. The Policy includes a waiver-of-subrogation provision that applies to the protection-and-indemnity coverage. A separate section of the Policy-governing hull-insurance coverage contains a waiver-of-subrogation provision and a provision naming Fieldwood as an additional insured. THE MASTER SERVICES CONTRACTS. Fieldwood executed the Master Services Contracts with Fluid Crane and United Fire, respectively. Fluid Crane and United Fire agreed to indemnify the other entities involved from claims asserted by their own employees, as well as to be responsible for defense costs for such claims. ANALYSIS Fieldwood’s Motion Fieldwood moved the Court to grant partial summary judgment enforcing waivers of subrogation in the Time Charter and Policy and dismissing Aries’s crossclaim and U.S. Specialty’s complaint-in-intervention. The Court held that Fieldwood is entitled to partial summary judgment because a review of the Time Charter and the Policy confirms that both Aries and U.S. Specialty have waived their rights of subrogation against Fieldwood. U.S. Specialty Waived Its Rights of Subrogation The Policy unambiguously waives U.S. Specialty’s right of subrogation in favor of Fieldwood. The Policy features a waiver-of-subrogation provision. The Time Charter qualifies as a “written contract” that “require[s]” U.S. Specialty to waive its rights of subrogation against Fieldwood because the Time Charter features a waiver-of-subrogation provision mandating that “[u]nderwriters of all policies of insurance required [by Section 10 of the Time Charter] shall waive their rights of subrogation against the Charterer Group,” which is defined to include Fieldwood. Because a review of the Time Charter and the Policy confirms that U.S. Specialty unambiguously waived its rights of subrogation against Fieldwood, and because the claims asserted in U.S. Specialty’s complaint-in-intervention rest on a subrogation theory, the Court granted Fieldwood’s motion for summary judgment and dismissed with prejudice U.S. Specialty’s complaint-in-intervention. The USDC concluded that the waivers of subrogation in Fieldwood’s favor are enforceable, and Aries and U.S. Specialty have not adequately presented any argument that would allow the Court to hold that their claims for defense and indemnity can survive despite the enforceability of those waivers of subrogation. Fieldwood’s motion for partial summary judgment was GRANTED. ZALMA OPINION Insurance policies like the marine policy interpreted in this case contain standard language authorizing the insured to waive the insurers’ right of subrogation if it does so before there is a loss. Since the litigants sought subrogation recovery which it had waived by the standard language of its policy this five year long litigation was resolved by the acceptance of the waiver. (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

Appear for a Scheduled EUO or Lose Failure to Honor Conditions Precedent Voids Coverage in New York Post 4937 Read the full article at https://www.linkedin.com/pulse/appear-scheduled-euo-lose-barry-zalma-esq-cfe-gvkec/, see the full video at and at and at https://zalma.com/blog plus more than 4900 posts. State Farm contended that it is entitled to summary judgment because of the failure to appear for examination under oath (EUO) by multiple defendants. State Farm contended that timely notices were properly mailed to the Claimants who failed to appear. In State Farm Mutual Automobile Insurance Company v. Alford A. Smith, M.D., et al, 2024 NY Slip Op 33802(U), Index No. 155607/2020, Motion Seq. No. 003, Supreme Court, New York County, Appellate Division (October 24, 2024) court ruled in favor of State Farm. The Supreme Court of New York County ORDERED that the plaintiff, State Farm Mutual Automobile Insurance Company’s (“State Farm/Plaintiff’), motion for summary judgment was GRANTED against defendants, Alford A. Smith, M.D., P.C., and the multiple other defendants who are doctors, chiropractors and other health services, (hereinafter collectively (“The Defendants”). FACTS The Supreme Court found that the EUO scheduling letters were timely requested and claimants failed to appear at that EUO. The documentary evidence showed that plaintiff sent the EUO scheduling letters to the claimants within 15 business days of receiving the prescribed verification forms as required by New York statute. FRAUD, FAILURE TO APPEAR FOR EUO & FAILURE TO SIGN TRANSCRIPT ARE BREACHES OF MATERIAL CONDITION PRECEDENT The Appellate Division upheld the Supreme Court’s ruling that the failure to appear for an EUO that was requested in a timely fashion by the insurer is a breach of a condition precedent to coverage and voids the policy ab initio. In addition, although claimant Griselda Torres unlike the other defendants, appeared for her EUO, Torres failed to return a subscribed copy of her EUO transcript. State Farm properly and effectively argued that appearing for and testifying at EUO and returning the transcripts of the EUO are conditions precedent to coverage and failure to sign and return the transcript warranted a denial of the claims. State Farm demonstrated in its motion and supporting evidence that multiple claimants breached a condition precedent to coverage by failing to appear for properly noticed EUOs on two separate occasions. Furthermore, claimant Griselda Torres’ failure to subscribe and return the transcript of her EUOsviolated a condition precedent to coverage and warranted denial of the claims. Moreover, there was nothing on the Court’s record to suggest that the scheduled EUOs were not justified, nor held at a place and time that was not reasonably convenient to the defendants. CONCLUSION State Farm’s motion seeking summary judgment in its favor was GRANTED as to THE multiple defendants and it was further ORDERED that any requested relief sought not expressly addressed herein has nonetheless been considered; and it was further ORDERED that the case shall continue against the remaining defendants; and it was further ORDERED that within 30 days of entry, plaintiff shall serve a copy of this decision/order upon the defendants with notice of entry. ZALMA OPINION The defendants in this case were doctors, physicians, chiropractors and other health care providers who billed State Farm for services provided to people who were injured in automobile accidents and assigned their rights to the providers who tried to collect their billings without complying with the EUO condition. They all lost their claims because they refused to appear except one defendant who appeared but failed to sign the transcript of the EUO and return it to State Farm. They all lost their claims and State Farm will continue its actions against many more defendants not subject to the motion. (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

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

Occam’s Razor Exclusion for Work Performed by Insured Defeats Claim for Construction Defects Post 4935 Read the full article at https://lnkd.in/gT_NsMHv, see the full video at https://lnkd.in/gqkPHYbp and at https://lnkd.in/gEEXkUe3, and at https://zalma.com/blog plus more than 4900 posts. The question presented to the U.S. First Circuit Court of Appeals was whether a contractor’s CGL insurance policy covers general damage to a non-defective part of the contractor’s project resulting from a subcontractor’s defective work on a different part of that project. APPLICATION OF OCCAM’S RAZOR The analysis technique that proposes that the simplest of competing theories be preferred to the more complex. FACTUAL BACKGROUND Applying Massachusetts law, the district court concluded that Admiral had no duty to defend Tocci in Admiral Insurance Company, Starr Indemnity & Liability Company, Great American Assurance Company v. Tocci Building Corporation, Tocci Residential LLC, John L. Tocci, Sr., No. 22-1462, United States Court of Appeals, First Circuit (November 8, 2024) and Tocci appealed. From 2013 to 2016, Tocci was the construction manager for an apartment project owned by Toll JM EB Residential Urban Renewal LLC (“Toll”). There were several work quality issues and delays on the project, and Toll eventually terminated Tocci in March 2016 for alleged mismanagement of the project. Toll sued with allegations regarding instances of defective work leading to property damage. The allegations included defective work by Tocci’s subcontractors resulting in various instances of property damage to non-defective work on the project, including (1) damage to sheetrock resulting from faulty roof work; (2) mold formation resulting from inadequate sheathing and water getting into the building; and (3) damage to a concrete slab, wood framing, and underground pipes resulting from soil settlement due to improper backfill and soil compaction. DUTY TO DEFEND Tocci sought defense and indemnity coverage under the Admiral insurance policies. Admiral denied coverage. The district court granted Admiral’s motion on duty to defend because the damage alleged in Toll’s complaint did not qualify as “property damage” as defined in the policy because the allegations consisted entirely of damage at Tocci’s own project. ANALYSIS The First Circuit considered three steps to the coverage analysis: (1) Do the damages alleged in the action fall within the scope of coverage?; (2) if so, do the exclusions to coverage apply?; and (3) if so, do any exceptions to the exclusions apply? The First Circuit noted that there is a sharp split of authority on whether damage to non-defective work resulting from a subcontractor’s defective work constitutes “property damage” or is caused by an “occurrence.” The First Circuit decided to avoid the issues of what constitutes “property damage” by focusing on the exclusions which were sufficient to resolve the complete dispute. THE HOLDING There are two “Damage to Property” exclusions that provide that there is no coverage for “property damage” to: that particular part of real property on which you or any contractors or subcontractors working directly or indirectly on your behalf are performing operations, if the ‘property damage’ arises out of those operations; or that particular part of any property that must be restored, repaired or replaced because “your work” was incorrectly performed on it. The First Circuit, applying Occam’s Razor, focused its analysis on the exclusion it concluded covers the allegations in the Toll complaint. Since the complaint alleges damage resulting from Tocci’s “incorrectly performed” work on the entire project “[t]hat particular part of any property that must be restored, repaired or replaced because ‘[Tocci’s] work’ was incorrectly performed on it” refers to the entirety of the project where Tocci was the general contractor charged with supervising and managing the project as a whole. Therefore, the First Circuit concluded that Admiral met its burden of establishing that the Toll action only alleges damage falling within the exclusion and that there was no exception to that exclusion that applied. ZALMA OPINION This is a case of a court applying Occam’s Razor, by picking an easy and obvious solution – the application of an exclusion – and avoiding the problem of different court rulings on coverage about “property damage” and “occurence.” Since the exclusion clearly applied there was no duty to defend. (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 Subscribe to my substack at https://lnkd.in/gmmzUVBy

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.