ZALMA’S INSURANCE FRAUD LETTER August 15, 2020

A ClaimSchool? Publication ? 2020, Barry Zalma & ClaimSchool, Inc., Go to my blog & Videos at: Zalma on Insurance at https://zalma.com/blog, Go to the Insurance Claims Library, Listen to the Podcast: Zalma on Insurance, Volume 24, Issue 16 – August15, 2020, Subscribe to e-mail Version of ZIFL, it’s Free! Read last two issues of ZIFL here. Go to the Barry Zalma, Inc. web site here, Videos from “Barry Zalma on YouTube”  

Quote of the Issue

 “Not Everything That Is Faced Can Be Changed, But Nothing Can Be Changed Until It Is Faced.” - James Baldwin

Pandemic or Not Serious Insurance Fraud Criminal Must Serve the Sentence

Attempt to Avoid Sentence Because Of Pandemic by Insurance Criminal Fails

Mikhail Zemlyansky is serving a 15-year sentence of imprisonment which was imposed in January 2016. He is currently incarcerated at the Federal Correctional Institution at Fairton, New Jersey. Defendant has moved for compassionate release under the First Step Act in light of the COVID-19 pandemic. The Government opposed the motion. In United States of America v. Mikhail Zemlyansky, 12-CR-171-01 (JPO), United States District Court Southern District Of New York (July 6, 2020) the warden failed to grant compassionate release and Zemlyansky appealed to the USDC.

FACTS

Defendant was convicted of running a wide-ranging racketeering enterprise that engaged in insurance fraud, securities fraud, and money laundering, among other crimes. Defrauded victims of the enterprise lost millions of dollars. For the reasons explained by the Court at sentencing, these crimes were extremely serious and he was sentenced to serve 15 years and had only served five to date.

LEGAL STANDARD

A court may not modify a term of imprisonment once it has been imposed except pursuant to statute. Under the First Step Act of 2018, a court is permitted to reduce a term of imprisonment if, after considering the factors it finds that extraordinary and compelling reasons warrant such a reduction and that such a reduction is consistent with applicable policy statements issued by the Sentencing Commission. The applicable policy statement outlines four circumstances that constitute “extraordinary and compelling reasons” and thus justify a sentence reduction. One of those circumstances is where the defendant is “suffering from a serious physical or medical condition that substantially diminishes the ability of the defendant to provide self-care within the environment of a correctional facility and from which he or she is not expected to recover. The policy statement also requires that the defendant not pose “a danger to the safety of any other person or to the community.”

DISCUSSION

Defendant is a 44-year-old man who suffers from hypertension and is overweight. He argues that these conditions place him at a high risk of severe complications in the event of a COVID-19 outbreak at the prison.

This Court in other cases has found “extraordinary and compelling reasons” warranting release to home incarceration based on serious health risks from the COVID-19 pandemic.

Although Defendant’s hypertension and weight likely place him at somewhat higher risk from COVID-19, they are relatively common conditions and Defendant is relatively young. When the parties filed their submissions, FCI Fairton appeared to have a low incidence of coronavirus infection among inmates. According to the latest information from the BOP, however, FCI Fairton has recently experienced an outbreak, with 97 inmates testing positive for COVID-19.

Despite the outbreak at FCI Fairton, the Court did not find “extraordinary and compelling reasons” that warrant Defendant’s release. Even if there were such reasons, the Court cannot conclude that release to home confinement now — approximately five years into a 15-year sentence — is justified based on consideration of the factors set forth in the statute.

The statutory purposes of specific deterrence and protecting the public from further crime, in addition to just punishment, respect for the law, and general deterrence, require Defendant to serve a substantial part of the sentence imposed by the Court.

For the foregoing reasons, Defendant Zemlyansky’s motion for compassionate release pursuant was denied.

ZIFL OPINION

A sentence of 15 years is only assessed upon a very serious insurance criminal. There is no question that Defendant Zemlyansky was a serious criminal who received a serious sentence. Just because he is fat and like most fat people has hypertension does not change the fact that he deserved to spend his time in prison to fulfill the statutory purposes of the criminal law. He was justly punished and that punishment may deter others. To allow the existence of a pandemic to allow him to avoid his just punishment defeats the purpose of the criminal law. He needs to, and will, serve his sentence.

Wisdom

“There is no such thing as failure, there’s just giving up too soon.” -- Jonas Salk

“All generalizations are dangerous, even this one.” – Alexandre Dumas

“Cultivation to the mind is as necessary as food to the body.” – Cicero

“A feeble executive implies a feeble execution of the government. A feeble execution is but another phrase for a bad execution; and a government ill executed, whatever may be its theory, must be, in practice, a bad government.” — Alexander Hamilton

“To be or not to be is not a question of compromise. Either you be or you don’t be.” — Golda Meir

“Against the insidious wiles of foreign influence … the jealousy of a free people ought to be constantly awake; since history and experience prove that foreign influence is one of the most baneful foes of Republican Government.” — George Washington

“History teaches us that men and nations behave wisely once they have exhausted all other alternatives.” — Abba Eban

“A ship in port is safe, but that’s not what ships are built for.” – Grace Hopper

No Escape from Insurance Fraud Conviction

Claiming Loss of Property That Did Not Exist After A Fire Sends Insured to Jail

To successfully defraud an insurance company the fraudster must use a modicum of skill, intelligence, and effort. When an insured presents a claim for expensive property he did not own, and did not have sufficient income and assets to own, resulted in arrest and conviction of the insured in The People Of The State Of New York v. Terrell L. Murray, 2020 NY Slip Op 04255, 299 KA 14-00921, Supreme Court Of The State Of New York Appellate Division, Fourth Judicial Department (July 24, 2020). After the trial court convicted defendant Terrell L. Murray (Murray) upon a jury verdict of insurance fraud in the third degree and falsifying business records in the first degree. Murray appealed.

ANALYSIS

The conviction arises from the filing of an insurance claim for various items of property that were ostensibly destroyed in a residential fire, which, upon investigation, was established to have been intentionally set.

The evidence of defendant’s prior misrepresentation on the relevant application for insurance was properly admitted in evidence to establish his intent to defraud. The Appellate Division concluded that the probative value of that evidence outweighed its potential for prejudice, and that the court’s limiting instructions minimized any prejudice to defendant.

Evidence of Murray’s poor financial condition was relevant to whether the contents of the subject claim forms were false inasmuch as it tended to prove that defendant did not actually own and possess in his residence the numerous expensive items of property that he claimed were destroyed in the fire. Any error in admitting that evidence is harmless inasmuch as the proof of defendant’s guilt, without reference to the error, is overwhelming, and there is no significant probability that the jury would have acquitted defendant had it not been for the error.

Defendant further contended that the court erred in granting the People’s request to instruct the jury on accessorial liability because doing so impermissibly introduced an alternative theory of liability, i.e., that he acted in concert with his wife, that was not charged in the indictment as amplified by the bill of particulars. The Appellate Division rejected Murray’s contention because an indictment charging a defendant as a principal is not unlawfully amended by the admission of proof and instruction to the jury that a defendant is additionally charged with acting-in-concert to commit the same crime, nor does it impermissibly broaden a defendant’s basis of liability, as there is no legal distinction between liability as a principal or criminal culpability as an accomplice.

Contrary to Murray’s contention, the accessorial liability instruction did not introduce any new theory of culpability into the case that was inconsistent with that in the indictment, and thus his indictment as a principal provided him with fair notice of the charges against him.

Viewing the evidence in the light most favorable to the People and affording them the benefit of every favorable inference there is a valid line of reasoning and permissible inferences which could lead a rational person to the conclusion reached by the jury on the basis of the evidence at trial.

Contrary to defendant’s specific contention, even if he did not personally complete and sign each claim form, the evidence is legally sufficient to establish that he “cause[d] to be presented” a written statement containing materially false information in support of a claim for payment pursuant to an insurance policy and caused a false entry in the business records of an enterprise by meeting with the insurance company’s representative and submitting to him the forms that were to be filed on defendant’s behalf.

ZIFL OPINION

As has been said from the beginning of time: “When you do the crime you must be ready to do the time.” Murray did the crime. The evidence was clear and overwhelming. Murray’s arguments against his conviction were weak and immediately disposed of, with little effort, by the New York Appellate Division.

Good News From the

* New Jersey fraud entrepreneur Christine Myers was a lead recruiter for an $8.8-million compound-med scheme. The plot targeted private and public health insurers that provided generous payouts for compound medications. Myers pocketed $1.5 million. She set up a marketing firm and hired sales reps to recruit people enrolled in insurance plans ripe for exploiting. Meyers’ sales team convinced the insureds with cash bribes and other methods to secure compound prescriptions — even if they didn’t need the goop. The insureds were told to send their ill-gotten prescriptions to designated telemed firms. The firms had the prescriptions filled at colluding compound pharmacies. Myers and her conspirators ran the scheme from 2015 to 2017 until the FBI blew it apart. She pled guilty to conspiracy to commit healthcare fraud, and faces up to 10 years in prison. Myers also must forfeit $1.47 million and pay at least $8.8 million in restitution.

* An exec at a DNA-testing firm bribed docs millions to order the firm’s tests of whether patients are at risk of drug addiction. Donald Joseph Matthews ran the $45-million scheme for Proove Biosciences, in Irvine, Calif. Matthews claimed the payments were for taking part in a clinical research program. But the money actually was tied to the volume of tests a doc ordered, and whether a doc continued ordering more tests from Proove. Docs who complained about not being paid were told to order more tests. Matthews admitted most docs weren’t interested in ordering Proove’s tests for their patients unless he bribed them. Matthews faces up to 5 years in federal prison when sentenced Oct. 26.

* Pay up, the feds told Karla Morales. The Bakersfield, Calif. dental office employee was convicted in 2018 for making 78 bogus claims for dental services she or family members never received. Morales was arrested this week for failing to repay nearly $44,000. The claim forms had the personal IDs and forged signatures of 4 dentists. All were her former employers. Morales and her husband received nearly $46,700. She was ordered to repay nearly $44,000.

* New Jersey fraud entrepreneur Christine Myers was a lead recruiter for an $8.8-million compound-med scheme. The plot targeted private and public health insurers that provided generous payouts for compound medications. Myers pocketed $1.5 million. She set up a marketing firm and hired sales reps to recruit people enrolled in insurance plans ripe for exploiting. Meyers’ sales team convinced the insureds with cash bribes and other methods to secure compound prescriptions — even if they didn’t need the goop. The insureds were told to send their ill-gotten prescriptions to designated telemed firms. The firms had the prescriptions filled at colluding compound pharmacies. Myers and her conspirators ran the scheme from 2015 to 2017 until the FBI blew it apart. She pled guilty to conspiracy to commit healthcare fraud, and faces up to 10 years in prison. Myers also must forfeit $1.47 million and pay at least $8.8 million in restitution.

* An exec at a DNA-testing firm bribed docs millions to order the firm’s tests of whether patients are at risk of drug addiction. Donald Joseph Matthews ran the $45-million scheme for Proove Biosciences, in Irvine, Calif. Matthews claimed the payments were for taking part in a clinical research program. But the money actually was tied to the volume of tests a doc ordered, and whether a doc continued ordering more tests from Proove. Docs who complained about not being paid were told to order more tests. Matthews admitted most docs weren’t interested in ordering Proove’s tests for their patients unless he bribed them. Matthews faces up to 5 years in federal prison when sentenced Oct. 26.

* Pay up, the feds told Karla Morales. The Bakersfield, Calif. dental office employee was convicted in 2018 for making 78 bogus claims for dental services she or family members never received. Morales was arrested this week for failing to repay nearly $44,000. The claim forms had the personal IDs and forged signatures of 4 dentists. All were her former employers. Morales and her husband received nearly $46,700. She was ordered to repay nearly $44,000.

Health Insurance Fraud Convictions

Highland Park, Texas Doctor Sentenced to 5.5 Years in Prison

Richard Ferdinand Toussaint Jr., 61, was ordered to pay more than $82.9 million in restitution and was sentenced to five-and-a-half years in prison. The anesthesiologist was sentenced August 9, 2020 for his part in the $200 million Forest Park Medical Center fraud case, federal prosecutors said.

Touissant is already serving a 41-month federal prison sentence for a separate health care fraud conviction. In March 2018, he pleaded guilty to his involvement in the Forest Park Medical case, admitting to one count of conspiracy to pay health care bribes and kickbacks and one count of illegal remuneration under the Travel Act.

The 66-month sentence will be served concurrent to the 41-month sentence. Toussaint admitted to collaborating with co-defendant Dr. Wade Neal Barker, a bariatric surgeon, to launch Forest Park Medical Center, a physician-owned hospital for bariatric and spinal surgery patients, in 2008, and then working with hospital manager Alan Andrew Beauchamp, Barker, and others to lure patients with high-reimbursing, out-of-network private insurance to the now-defunct hospital by paying surgeons for referrals.

Most of the $40 million in kickbacks were euphemistically called consulting fees or “marketing money,” and was disbursed as a percentage of surgeries each doctor referred to the hospital. An email trail corroborated this, as did Toussaint.

Dr. Toussaint was one of 18 convicted. Barker, Beauchamp, Kelly Wade Loter, David Daesung Kim, Israel Ortiz, Andrea Kay Smith, Frank Gonzales, Jr., Andrew Jonathan Hillman, and Semyon Narosov pleaded guilty before trial. Wilton McPherson “Mac” Burt, Jackson Jacob, Douglas Sung Won, Michael Bassem Rimlawi, Shawn Mark Henry, Mrugeshkumar Shah, and Iris Kathleen Forrest were convicted after their trials.

Doctor and Assistant Plead Guilty to Unlawfully Distributing Opioids

Scotty Akers, M.D., 48, a licensed physician, and Serissa Akers, 33, his wife and former office assistant, both of Pikeville, Kentucky, pleaded guilty to unlawfully distributing controlled substances. As part of the plea, Scotty Akers also agreed to a money judgement of $12,275. Sentencing has been scheduled for November 20, 2020.

Akers, a Kentucky doctor and his office assistant pleaded guilty August 10, 2020 for their roles in unlawfully distributing opioids and other controlled substances during a time when the defendants did not have a legitimate medical practice.

As part of their guilty pleas, the defendants admitted to using Facebook messenger to sell unnecessary prescriptions for opioids. According to their plea agreements, Serissa Akers exchanged prescriptions written by Scotty Akers for cash in parking lots around Pikeville. The defendants also admitted that they performed no physical examinations that would justify these parking-lot prescriptions, failed to keep virtually any records on the patients who received these prescriptions, allowed patients to receive early refills, and failed to engage in other measures that prevent the abuse and diversion of opioids. The defendants continued operating their opioid-delivery scheme even after they came under investigation and up until the moment when Scotty Akers’s medical license was suspended. 

The convictions resulted from the work of the ARPO Strike Force is made up of prosecutors and data analysts with the Department of Justice’s Fraud Section, prosecutors with the ten U.S. Attorney’s Offices in the Appalachian region, and special agents with the FBI, HHS-OIG and DEA. The ARPO Strike Force operates out of two hubs based in Ft. Mitchell, Kentucky, and Nashville, Tennessee, areas, supporting the ten districts that make up the ARPO Strike Force region.

Since its inception in October 2018, the ARPO Strike Force, which operates in ten districts, has charged more than 70 defendants who are collectively responsible for distributing approximately 50 million pills. Thus far there have been 30 guilty pleas as a result of ARPO Strike Force’s efforts. The ARPO Strike Force is part of the Medicare Fraud Strike Force Program, led by the Fraud Section. Since its inception in March 2007, the Medicare Fraud Strike Force, which maintains 15 strike forces operating in 24 districts, has charged more than 4,200 defendants who have collectively billed the Medicare program for approximately $19 billion. In addition, the U.S. Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services, working in conjunction with the HHS-Office of Inspector General, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Connecticut Dentist Pays Over $148k To Settle Improper Billing Allegations

EAN JAMES, D.M.D., entered into a civil settlement with the federal and state governments in which he will pay more than $148,000 to resolve allegations that he caused overpayments to be paid by the Connecticut Medicaid Program.

James is an oral and maxillofacial surgeon who practices at Hartford County Oral Surgery in Bristol and Rocky Hill. The government’s allegations against James arise out of billing Medicaid for sedation and anesthesia services without a valid permit to perform those services.

In order for a dentist to administer moderate or deep sedation or general anesthesia to patients during dental procedures, the State of Connecticut requires the practitioner to have an active permit to perform conscious sedation, issued by the Connecticut Department of Public Health (“DPH”). This conscious sedation permit must be renewed annually. If the annual deadline to renew the conscious sedation permit lapses, there is a 90-day grace period during which a dentist may still administer anesthesia and sedation under the expired permit and may still apply for a renewal. Once the grace period expires, the permit becomes void. The dentist may not administer anesthesia or sedation, and must apply for a new permit if he or she wishes to resume providing those services.

On April 30, 2018, James’ conscious sedation permit lapsed. He failed to renew his permit and, on August 1, 2018, the 90-day grace period expired. Despite not having an active permit, James continued to provide anesthesia and sedation services to Medicaid patients undergoing certain oral surgical procedures, and billed Medicaid for these services. The government alleged that these claims for sedation services performed without a valid permit were improper.

To resolve his liability, James will pay $148,632.23 to the federal and state governments for conduct occurring between August 1, 2018, and June 7, 2019.

VP Of Genetics Company Pleads Guilty To $21 Million Medicare Fraud Scheme

Donald Joseph Matthews, the former Vice President of Market Development for Proove Biosciences. Inc., pleaded guilty in federal court today to conspiring to pay physicians kickbacks to order genetic tests for Medicare beneficiaries in violation of the Anti-Kickback Statute.

According to Matthews’ plea agreement, Proove paid doctors at least $3.5 million to induce them to order Proove’s DNA tests—which the company claimed could determine a patient’s risk of abusing certain prescription narcotics. Proove billed approximately $45 million to the Medicare program for the tests, in violation of Medicare’s prohibition against kickbacks, and Proove received approximately $21 million in unlawful payments. Proove concealed the true nature of the kickbacks by falsely characterizing the payments as compensation for participating in a clinical research program sponsored by Proove. In furtherance of the scheme, Proove placed its own employees in doctors’ offices. The Proove employees collected a cheek swab and completed most of the paperwork associated with the “clinical research” program. Without the financial compensation, Matthews admitted that most doctors were not interested in ordering Proove’s tests for their patients.

The compensation Proove paid to doctors was directly tied to the volume of tests that a doctor ordered and whether a doctor continued to order more tests from Proove over time. When doctors were not paid, they threatened to “pull the plug” and stop ordering Proove’s genetic tests. When the doctors complained about delayed payments, a Proove executive demanded that the doctors increase their testing volume. 

Matthews pleaded guilty August 4, 2020 before U.S. Magistrate Judge Karen S. Crawford. His sentencing is scheduled for October 26, 2020 at 9:00 a.m. before U.S. District Judge William Q. Hayes.

Videos on YouTube And Zalma On Insurance from Barry Zalma

62 Videos describing important insurance issues described by Barry Zalma and available to anyone who views or subscribes to the YouTube account. Issues include insurance fraud, definition of insurance, insurance as a contract of personal indemnity, millions for defense and not a dime for tribute and the tort of bad faith. Please subscribe. The 62 videos are at https://www.youtube.com/channel/UCFg7qxC0tVgKcMUqoUfnwPw/videos bit I have had some difficulty posting new videos to my YouTube channel and have decided to post all future videos on insurance, insurance claims, insurance law, and insurance fraud to this YouTube Channel and my blog, https://zalma.com/blog.

 Other Insurance Fraud Convictions

Phillipsburg Woman’s Prescription Fraud Ring Bilked Insurance, Taxpayers Out Of $8.8m

Christine Myers pocketed almost $1.5 million in the scheme to get insurance reimbursements for phony prescriptions and faces up to a decade in prison, according to a news release. Myers, a 38-year-old Phillipsburg, New York woman admitted to her role in an insurance fraud scheme that cost public and private health plans at least $8.8 million by filling fake prescriptions for compounded medicines.

Myers, the former co-owner of a New Jersey marketing company pleaded guilty to conspiracy to commit healthcare fraud via video conference before U.S. District Judge John Michael Vazquez. As part of her plea deal, Myers must give up the $1.475 million she netted in the scheme and pay restitution of at least $8.8 million. Sentencing is scheduled for Dec. 1.

Because pharmacists mix compounded medications for patients when a physician determines a Food and Drug Administration-approved medicine would not work, for example, if a patient is allergic to dye in a prescription, the medication becomes more expensive. Certain insurance plans pay “exorbitant reimbursement rates” for some compounded medicines, including scar and wound creams and metabolic supplements and vitamins.

Those involved in the scheme discovered this and from February 2015 until February 2017 they created an elaborate system to submit fake prescriptions for compounded medicine to public and private insurance plans. Myers created a marketing company and hired sales representatives to target people who had insurance plans that covered compounded medications. The sales reps got those individuals to obtain prescriptions for the medicines, even if they did not need them, often by paying them cash. They were then directed to send the prescriptions to specific telemedicine companies, which Myers’ company or its affiliates paid.

The prescriptions were filled by certain compounding pharmacies that were co-conspirators with Myers’ company. The pharmacies would be reimbursed by the insurance plans and pay Myers’ company a percentage of the reimbursement. Myers then pocketed a portion of the payment and paid her sales rep a commission.

Two of the sales representatives -- Christopher Frusci and Enver Kalaba -- are former Metropolitan Transportation Authority employees. Since the MTA’s health plan covered compounded medicines, Frusci and Kalaba targeted workers at the agency and paid them cash bribes for every compounded prescription they submitted.

On Feb. 7, 2019, Kalaba was sentenced to 20 months in federal prison and one year of supervised release. He must give up the $138,630 he made in the scheme and pay back $2.9 million in restitution.

“Ring Leader” In New Orleans Staged Accident Scam Pleads Guilty

Damien Labeaud, 48, confessed to being the ringleader in multiple fake accident schemes, including two wrecks in almost the exact same location six days apart in June 2017.

Labeaud’s plea to conspiracy to commit wire fraud turns up the heat on the one remaining defendant, as well as the attorneys who federal prosecutors say worked with Labeaud to stage accidents in order to collect lucrative settlements from lawsuits.

Labeaud is described by the prosecutors as being in regular contact with “Attorney A” before and after the accidents. Both the accidents listed in the indictment were followed by lawsuits filed on behalf of the passengers by New Orleans attorney Daniel Patrick Keating.

In a statement, the U.S Attorney’s office wrote, “According to today’s guilty plea, Labeaud staged numerous accidents for various attorneys, including at least 40 staged accidents with 18-wheeler tractor-trailers for Attorney A.”

The press release continued, “After each staged accident, Labeaud would connect the passengers in the staged accidents with Attorney A so that Attorney A could represent them in conjunction with the accident. Attorney A would then pay Labeaud $1,000.00 for every passenger.”

Four women from Houma, Louisiana – Lucinda Thomas, 63, Mary Wade, 55, Judy Williams, 59, and Dashontae Young, 25 – pleaded guilty last year for their roles in an accident near the Danziger Bridge on June 6, 2017. Another defendant, Larry Williams, admitted he was involved in a staged accident with a truck six days later at almost the same location. Another defendant, Genetta Israel, was in the car with Williams and is awaiting trial.

In both of those accidents, Labeaud confessed to being the “slammer” – or driver – who would intentionally ram into an 18-wheeler. In the June 6 accident, Labeaud re-appeared on the scene after police arrived, pretending to be an independent witness. Police body cam footage exclusively obtained by WWL-TV shows Labeaud driving up the crash scene with another named defendant, Mario Solomon. Solomon, 48, pleaded guilty in May to wire fraud conspiracy for his role as a “spotter,” acting as a witness to the manufactured accidents. Labeaud and Solomon face a maximum of five years in prison for their roles in the scam, while the other defendants could face longer sentences for their guilty pleas to additional counts of wire fraud.

Man Who Ran Insurance Fraud Racket in Malta By Crashing Cars Gets Three Years’ Jail

Over five years, all of Malta’s insurance companies were targeted in insurance fraud racket

Josef Grech, now 45, was found guilty on his own admission of defrauding the Untours, United, GasanMamo, Citadel, Atlas, Elmo, Allcare, and Thomas Smith insurance agencies out of over €5,000 each, and of filing false police reports.

The court of Criminal Appeal confirmed a jail sentence for Grech who ran an insurance fraud racket between 2009 and 2013, which intentionally crashed cars for insurance money.

He was found guilty of destroying his own property to claim insurance, breaching a condition of a suspended sentence and relapsing. Grech was sentenced to three and a half years in prison.

Some 22 people were originally charged when the police unraveled the scam in 2016. It is understood that the insurance firms found that some individuals had filed accident claims on several vehicles they owned. People were also agreeing to be involved in “traffic accidents” and would then file separate claims with their own insurance agencies.

Grech’s lawyers argued in the appeal that the punishment was excessive and should be reduced. The accused had pleaded guilty at an early stage, cooperated with the police and accepted to compensate the victims for the damages they suffered as a result of his criminal actions.

They submitted that the court of first instance had wrongly treated him as a mastermind, whereas in fact he was simply an accomplice. He denied that he was the brains behind the scam and said that he was being made a “sacrificial lamb” for other people’s crimes.

But the court of criminal appeal took into account that the appellant had been convicted of no less than 21 charges, primarily fraud, when the appellant and his accomplices created a mise en scene to defraud insurance companies by creating street accidents and car collisions.

The court noted that given the number and nature of the charges against the man, his three-and-a-half-year sentence was close to the minimum which could be imposed. Neither was it the case that a non-custodial sentence could be handed down, according to the court.

Grech had systematically and repeatedly, over the period between 2009 and 2013, created a danger to road users by staging crashes and claiming insurance. The Court of Criminal Appeal had its hands tied, it said, not only because the court of first instance had used its discretion justly and wisely in awarding punishment, but also in view of the report of the man’s probation officer who said that in the particular circumstances of this case, only a custodial sentence would protect the interests of both appellant and his victims.

Baltimore City Counselor Pleads Guilty to Felony Medicaid Fraud – Five Years Suspended

Roshun J. Harris, of Randallstown, Maryland pleaded guilty to one count of felony Medicaid Fraud for submitting claims that caused the Maryland Medical Assistance Program (Medicaid) to reimburse Harris with more than $18,000 for services that she did not provide.

Harris is a licensed clinical professional counselor who operated a private mental health practice. From January 2012 through May 2017, she submitted false claims in connection with her private mental health practice. Specifically, Harris submitted claims to Medicaid and was reimbursed for services that she did not provide to her clients because her clients were either hospitalized or at work and not meeting with Harris in their homes.

Harris was sentenced to five years incarceration, all suspended, five years of supervised probation, and ordered to pay restitution to Medicaid in the amount of $18,408.79. As a condition of Harris’s probation, she is prohibited from working for any provider in a federally-funded health care program for five years.

1938 New Jersey Minister Guilty of Murder for Insurance Funds

Walter Dworecki solicited the murder of his daughter Wanda Dworecki who was murdered near Camden High School. She had been beaten, strangled, and her head bashed in with a rock. The murder took a more scandalous turn when it was determined that Wanda’s father, a Baptist preacher, had paid to have her killed so he could collect insurance money, about $2600. He paid her killer 50 cents.

Witnesses testified that Walter Dworecki, the father, had tried to solicit other men to kill his daughter. She was described as a “wild girl” who might sully her father’s reputation and he had taken out the most recent insurance policy a mere three weeks before her untimely demise.

Walter had also collected insurance money on his wife’s death; arsenic poisoning was suspected but never proved. Wanda died at the hands of a boarder in the Dworecki home, Pete Shewchuck a carnival roustabout and handyman who was described as “slow” and strong. He had a previous intimate relationship with the teenage girl and, on the night of the murder, took her out on a date. The Reverend Dworecki had given Shewchuck 50 cents for expenses. He walked with Wanda to a “lover’s lane” near the Camden High School athletic fields where he beat her, strangled her, and then, for good measure, crushed her head with a rock. Shewchuk was identified as the person last seen with Wanda, and, after a manhunt, was arrested.

He confessed to everything, claiming that the pastor had offered him $100 to kill his daughter, but he had collected only 50 cents. After playing the role of bereaved father, Rev. Dworecki also confessed, although he claimed at trial that the police had beaten the confession out of him.

It took a jury twelve hours to come to a conclusion: guilty of first degree murder; Dworecki was sentenced to death. He was found guilty in October of 1939 and was executed (via electric chair) in March of 1940. Swechuk was tried separately; he was also found guilty but was sentenced to life in prison. He was paroled in 1958.

California Department of Insurance Fraud Lawsuit Results in Reforms of HUMIRA Marketing And $24 Million Payment by Drugmaker Abbvie

Department lawsuit had alleged insurance fraud by AbbVie in promoting its blockbuster prescription drug HUMIRA

In a Press Release from the California Department of Insurance (CDOI) Insurance Commissioner Ricardo Lara on August 6, 2020today announced a settlement agreement with AbbVie Inc. to resolve a lawsuit alleging violations of the California Insurance Frauds Prevention Act (Act) involving the marketing of blockbuster prescription drug HUMIRA. AbbVie agreed to reform its HUMIRA marketing practices in California, including disclosing that registered nurses employed as “Ambassadors” to interact with patients about HUMIRA are actually paid by the company, not a medical provider, and reforming how HUMIRA is marketed to health care providers. In addition, as provided for in the Act, AbbVie has also paid a combined $24 million to the State of California and the whistleblower who brought the case to the Department’s attention.

“AbbVie’s prior practices in marketing HUMIRA egregiously put profits ahead of transparency in patient care and violated California law,” said Commissioner Lara. “This settlement delivers important reforms to AbbVie’s business practices and a substantial monetary recovery that will be used to continue to combat insurance fraud.”

In October 2016, the Department began an investigation into AbbVie after receiving a whistleblower case filed by a registered nurse who was employed as an AbbVie Ambassador in Florida. After its investigation, the Department intervened in that case and filed a Superseding Complaint alleging that AbbVie violated California’s Insurance Frauds Prevention Act. Among other things, the Department alleged that AbbVie violated the Act by unlawfully providing free and valuable professional goods and services to physicians to induce and reward HUMIRA prescriptions. The Department alleged that Nurse Ambassadors interfered with the flow of doctor-patient communications and did not directly answer questions pertaining to HUMIRA’s side effects. The Department also alleged that other HUMIRA marketing activities constituted kickbacks in violation of the Act, including, for example, the provision of meals and drinks to providers outside the context of speakers programs.

While AbbVie continues to deny the allegations, as a part of the settlement, AbbVie agreed to reforms, including:

• Ambassadors will disclose to patients that they are provided by AbbVie and do not work under the direction of the patient’s health care provider.
• The company will implement a policy modification prohibiting HUMIRA sales representatives from inviting HUMIRA prescribing health care providers to offsite business meals, except as part of the AbbVie speaker programs. 
• AbbVie will provide patients with the U.S. FDA-approved HUMIRA medication guide and Ambassadors will direct patients to the medication guide and their health care provider regarding side effects and safety risk.
• The company will provide guidance and training that Ambassadors shall not have patient-specific discussions with providers who prescribe HUMIRA.
• AbbVie employees will be prohibited from describing Ambassadors to health care providers as “extensions of their offices” and from providing to providers any contact information for Ambassadors who interact with HUMIRA patients.
• AbbVie employees and Ambassadors will not actively participate in conversations between patients and insurance companies.

The complete list of AbbVie’s business practice reforms can be found in the settlement.

The settlement agreement can be found here.

Guilty of Workers’ Compensation Fraud

Marlene Cavalcanti, 40, pleaded guilty to two felony counts of insurance fraud and identity theft after falsifying documents to receive an additional $10,590 on her workers’ compensation claim.

Cavalcanti, employed as an executive assistant, reportedly fell at work and sustained injuries. As a result of her subsequent workers’ compensation claim, Cavalcanti received more than $42,000 in total temporary disability payments in addition to her medical treatment. An investigation by the Department of Insurance revealed after being placed on disability, Cavalcanti ceased medical treatment and began working for another company. During this time, she submitted multiple fictitious doctors reports in an attempt to continue to receive disability payments from the workers’ compensation insurance company. When confronted by detectives, Cavalcanti ultimately admitted to the fraudulent documents and forged doctors’ signatures.

During the investigation, department detectives discovered Cavalcanti attempted to file a new workers’ compensation claim at a different insurance company with her new employer. The new workers’ compensation claim dates and injuries were similar and overlapped with her initial claim. The investigation by detectives prevented payment on this subsequent fraudulent claim and the insurance company incurred no loss.

Cavalcanti is expected back in court September 9, 2020 for sentencing. The Marin County District Attorney’s Office prosecuted this case.

Bakersfield Dental Office Employee in Jail for Failing to Pay Restitution

Karla Morales, 42, was arrested August 5, 2020 for failing to pay restitution after being sentenced in an elaborate $46,000 insurance fraud scheme. In November 2018, Morales was sentenced to one year in jail, five years probation and ordered to pay $43,987.70 in restitution.

In June 2018, Morales was charged with 45 felonies, including insurance fraud, identity theft, forgery, and grand theft after Department of Insurance detectives discovered she had submitted 78 fraudulent dental insurance claim forms for services she or her family never received. The fraudulent claims forms contained personal identifying information, including forged and/or electronic signatures, of four different treating dentists, all of whom are Morales’ former employers.

Morales used her dental industry knowledge, gained by working for these providers, to successfully submit the fraudulent insurance claims for reimbursement. She then conspired with her husband, Raymundo Morales Jr., 47, who was also charged in June 2018, to cash and/or negotiate the reimbursement checks made payable to him as the dental insurance policy holder. The total paid in fraudulent insurance payments was $46,688.21. 

Morales has been booked into the Kern County Jail and is being held without bail. The Kern County District Attorney’s Office is prosecuting this case. Usually, restitution orders are made in exchange for jail time but hold that if the restitution is not paid the defendant serves the time assessed.

Sentenced For ‘Crash and Buy’ Insurance Fraud

Riley Presher, of Twin Falls, Idaho, was sentenced on August 9, 2020 for insurance fraud in violation of Idaho Code 41-293.

Presher purchased insurance and filed a claim for an accident he stated occurred that same day. When the investigations division with the Idaho Department of Insurance was asked to look into this claim and Presher was interviewed, he reportedly admitted to DOI Investigators he did not have insurance on the day the accident happened when he backed his truck into his friend’s vehicle.

Presher eventually admitted to misrepresenting the collision date and time to Sentry Insurance in the hopes to offset the cost from the damage he caused to his friend’s vehicle. Presher pleaded guilty to insurance fraud in May.

Fifth District Court Judge Rosemary Emory sentenced Presher to a unified sentence of five years in prison. Emory then suspended the sentence and placed Presher on five years of supervised probation.

Presher was ordered by the court to serve 120 days of jail time with options and 150 hours of community service. Emory also gave Presher the option of serving an additional 150 hours community service in lieu of the 120 days jail time in consideration of the COVID-19 pandemic.

Presher was ordered to pay a $750 fine and court costs. He will also pay $1,260 in restitution to the Idaho Department of Insurance and $1,943 to Sentry Insurance.

Legal Disclaimer

ZIFL is made available by the publisher for educational purposes only as well as to give you general information and a general understanding of the law, not to provide specific legal advice. By using ZIFL you understand that there is no attorney client relationship between you and the publisher. ZIFL should not be used as a substitute for competent legal advice from a licensed professional attorney in your state. The author and publisher disclaim any liability, loss, or risk incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this blog. The information provided is not a substitute for the advice of a competent insurance, legal, or other professional. The Information provided at this site should not be relied on as legal advice. Legal advice cannot be given without full consideration of all relevant information relating to an individual situation.

Consider Books to Show Your Appreciation to Your Insurer Clients or Claims Employees

Many insurers refuse to allow their employees to receive gifts from vendors.

If you wish to thank your insurance company clients for allowing you to represent their interest or if you wish to honor your claims personnel it is time to give them something that will be useful to them throughout the coming year and that will not offend insurer’s rules to avoid attempts to extort clients for business from insurer employees.

The Insurance Claims Library

Over the last 51 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to make it for insurers and their claims staff to become insurance claims professionals.

Consider the Insurance Claims Library where, for a small investment you can provide each claims office – rather than individual adjusters – a group of insurance books that will help them throughout the year.

By providing clients, claims departments, or claims personnel with any one or more of the books offered by the Insurance Claims Library. By so doing you can add to the insurance claims professionalism of your clients, employees and claims personnel. With delivery handled by Amazon.com any one or more of the following books, all available from amazon.com and https://zalma.com/blog/insurance-claims-library/, will gain the respect and gratitude from each recipient and their employers.

Books Available from the Insurance Claims Library

The Homeowners Insurance Policy – How to Buy an Appropriate Homeowners Policy and Successfully Make a Claim to the Insurer; Zalma on Insurance Claims – Second Edition – Ten volumes providing a Comprehensive Review of insurance, insurance claims, the law of insurance and policy interpretation Paperback; Construction Defects and Insurance; Mold Claims; The Law of Unintended Consequences and the Tort of Bad Faith; Insurance Fraud – Volume I & Volume II; The Compact Book of Adjusting Property Insurance Claims – Second Edition; The Compact Book on Adjusting Liability Claims, Second Edition; California Fair Claims Settlement Practices Regulations; California SIU Regulations; Ethics for the Insurance Professional; Rescission of Insurance – 2nd Edition; The Insurance Examination Under Oath; and six Fictionalized True Insurance Crime Books. Available at https://zalma.com/blog/insurance-claims-library.

Books from Full Court Press

“Zalma on Property and Casualty Insurance”, “Insurance Law Deskbook”, “California Insurance Law Deskbook”, and “Insurance Bad Faith and Punitive Damages Deskbook”

Learn Everything You and Your People Need to Know About Insurance at reduced prices now only $95.00.

The Insurance Law Deskbook

The Insurance Law Deskbook is intended to help law students, practitioners, insurance lawyers, professional claims personnel, insured persons, and anyone else involved in insurance. The book, published for the first time under Full Court Press, includes the full texts and digests of insurance-related decisions of the U.S. Supreme Court, the U.S. District Courts of Appeal, state appellate courts, and foreign courts that have molded the American insurance law, as well as vital explanatory chapters, historical context, form letters, and more.

Paperback, only $95.00 available at https://www.fastcase.com/store/fcp/insurance-law-deskbook-2/

California Insurance Law Deskbook

ISBN: 978-1-949884-28-9 (Print) 978-1-949884-30-2(Ebook)

Format: Digital (Epub, Mobi, PDF), Print

California has long led the way when it comes to insurance jurisprudence in the United States, and few know more about California insurance law than Barry Zalma.

Available at https://www.fastcase.com/store/fcp/california-insurance-law-deskbook/ a paperback for only $95.00.

Insurers must bring a new crop of graduates into the insurance profession. Since most insurer-based insurance training departments have been eliminated there is a need for other means to train a new generation of claims professionals. All available at fastcase.com.

Information needed by every claims person and insured. They are available on amazon.com and at https://zalma.com/blog/insurance-claims-library/ or the individual links at each described book. Web based training is available at experfy.com and illumeo.com or you can have Barry Zalma present the training live to your personnel.

Read more about Barry Zalma, Inc. at https://www.zalma.comThe earnings of almost every civil lawyer in the United States are funded by the insurance industry. Insurance can best be described as the mother’s milk of the law profession. The civil defense lawyer is paid by an insurer for each hour he or she works. The civil plaintiffs’ lawyer is usually paid by taking a percentage of any judgment entered in favor of the plaintiff, which judgment is usually paid by the defendant’s insurer.

In almost every situation in which a civil lawyer practices law the funds for that work come, either directly or indirectly, from insurance. Consequently, lawyers must use their wits and energies to avoid or to pursue litigation to the benefit of the client. Both sides understand that an insurer will eventually pay one or both sides in the dispute. Insurance is important to every civil dispute and even some that fall within the criminal courts.

Every lawyer retained to prosecute or defend a civil suit should begin the representation with a serious effort to find insurance coverage for the benefit of the client or the defendant the client is suing. Without that knowledge, the lawyer will find he or she is litigating with duct tape firmly self-placed across his or her mouth.

Books from the American Bar Association

“Getting the Whole Truth: Interviewing Techniques for the Lawyer” by Barry Zalma, Esq., CFE

Learn techniques that can help you interact with others and effectively gather the facts you need.

The purpose of an interview is to uncover the truth; the method of uncovering the truth is the art of the interview. Obtaining sufficient relevant information is imperative in everything a lawyer does to protect the interests of the client, yet interviewing techniques are not emphasized in law school training.

Getting the Whole Truth teaches lawyers–from novices meeting their first clients to experienced trial lawyers–effective methods of obtaining information by human interaction. No matter from whom you are seeking information or what your reason for desiring it, these techniques can help you meet and interact with others and effectively gather the facts you need.

Listen to podcast about the book at https://www.americanbar.org/groups/gpsolo/podcasts/gpsolo-podcast-july-2020-hotp-interview-techniques/

$59 Non-Members, $44 Members

”The Commercial Property Insurance Policy Deskbook” By Barry Zalma

“How to Acquire a Commercial Property Policy and Present and Collect a First-Party Property Insurance Claim

The Commercial Property Insurance Policy Deskbook is a comprehensive resource on acquiring a commercial property policy and presenting and collecting first-party property insurance claims. The book looks at the fundamentals of insurance and a wealth of topics including rules of construction of a policy of commercial property insurance, the commercial first party property insurance policy, different types of property losses, conditions and limitations, specific and blanket cover.” Available here.

"The Insurance Fraud Deskbook”

Author: Barry Zalma, ISBN: 978-1-62722-676-9, Product Code: 5190506, 2014, 638 pages, 7 x 10

This book is written for individuals who are focused on the effort to reduce expensive and pervasive occurrences of insurance fraud. Lawyers who represent insurers, claims personnel, prosecutors and their investigators can all benefit from this exhaustive resource.

The Insurance Fraud Deskbook is a valuable resource for those who are engaged in the effort to reduce expensive and pervasive occurrences of insurance fraud. It explains the elements of the crime and the tort to claims personnel, and it provides information for lawyers who represent insurers, so they can adequately advise their clients. Prosecutors and their investigators can use this book to determine what is required to prove the crime and win their case.

The full text of decisions from courts of appeal and supreme courts across the country are provided so the reader can understand what happens after the investigation is completed and can apply that information to undertake their own thorough investigations. It allows claims personnel and their lawyers to understand what errors would cause a defeat or a not-guilty verdict.

The effort to reduce insurance fraud requires the assistance of both civil and criminal courts.

The Insurance Fraud Deskbook can help the prudent fraud investigator, insurance adjuster, insurance attorney, insurance Special Investigation Unit, and insurance company management to attain the information needed to deal with state investigators and prosecutors.

Available from the American Bar Association at: https://shop.americanbar.org/eBus/Default.aspx?TabID=251&productId=214624; or [email protected], or 800-285-2221.

“Diminution in Value Damages”

How to Determine the Proper Measure of Damage to Real and Personal Property

ISBN: 978-1-63425-295-8

Product Code: 5190524

2015, 235 pages, 7 x 10, Paperback

Available from Thomson Reuters

“Property Investigation Checklists Uncovering Insurance Fraud, 12th Edition”

This edition has been totally rewritten and expanded, providing the most extensive and detailed coverage of the issue and a thorough explanation of how to apply diminution in value damages to losses to property. Property Investigation Checklists: Uncovering Insurance Fraud provides detailed guidance and practical information on the four primary areas of any investigation of suspicious claims. The book also examines recent developments in areas such as arson investigation procedures, bad faith, and extracontractual damages. The appendix includes the NAIC Insurance Information and Privacy Protection Model Act. Also included are five appendixes of forms, letters, and other documents.

Available here

New and Now Available from the Zalma Insurance Claims Library

The Insurance Examination Under Oath Second Edition

A Tool Available to Insurers to Thoroughly Investigate Claims and Work to Defeat Fraud

A Tool Available to Insurers to Thoroughly Investigate Claims and Work to Defeat Fraud.

The insurance Examination Under Oath (“EUO”) is a formal type of interview authorized by an insurance contract. It is taken under the authority provided by the agreement of the insurer, when he, she or it acquires a policy of insurance, to submit to a condition of the insurance contract that compels the insured to appear and give sworn testimony at the demand of the insurer. Failure to appear and testify is considered a breach of a material condition.

The EUO is conducted before a notary and a certified shorthand reporter who is present to give the oath to the person interviewed. The reporter will record the entire conversation and prepare a transcript to be read, reviewed, corrected and signed by the witness under penalty of perjury or by an oath taken before a notary or judge.

The EUO is a tool only sparingly used by insurers in the United States. A professional insurer will only require an insured to submit to an EUO when a thorough claims investigation raises questions: About the application of the coverage to the facts of the loss, the potentiality that a fraud is being attempted, or to assist the insured in the obligation to prove to the insurer the cause and amount of loss.

Although seldom used the EUO is an important tool needed by insurers when there is a question of coverage, destruction of evidence needed to prove a compensable loss or the amount of loss or evidence indicating the potential that a fraud is being attempted. The EUO and Legal Action provisions in an insurance policy are conditions precedent to an insured’s ability to file suit, and that since the insured failed to substantially comply with the terms of those provisions, the appropriate remedy is dismissal without prejudice. The insured’s failure to comply with these conditions does not bar his ability to bring suit to recover, but merely suspends his ability to bring suit until he has fully complied with those conditions.

Available as a paperback here or Available as a Kindle book here

The Little Book on Ethics for the American Lawyer

by Barry Zalma (Author)

The practice of law demands more than knowledge of statutory and case law. It requires more than technical proficiency in the nuts and bolts of legal practice. A lawyer is an officer of the legal system whose conduct should conform to the requirements of the law, both in professional service to clients and in the lawyer’s business and personal affairs.

The practice of law requires that every lawyer treat each client, each adversary, and the court ethically and in good faith.

The practice of law is different from other professions because it requires that the lawyer act for his or her client, not him or herself, only if the actions for the client are ethical and in good faith.

What is Ethical Behavior?

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 also refers to the study and development of one’s standards of conduct. Feelings, laws, and social norms can deviate from what is ethical. It is necessary, especially to people involved in the practice of law, to constantly examine one’s standards to ensure that they are reasonable and well-founded conduct that ethically treats a client, an adversary, and the court with the utmost good faith.

There is no single answer to the question of what is ethical behavior by a lawyer. Ethical behavior is subjective and fact dependent.

“Arson-For-Profit Fire at the Cowboy Bar & Grill”

A true crime novel based on the experience of the author, Barry Zalma, who for more than 51 years has acted for insurers who were faced with arson-for-profit, one of the most dangerous insurance fraud schemes. The book explains how an insurance claims adjuster, working with a fire cause and origin expert, a forensic accountant and insurance coverage lawyer, were able to defeat an arson-for-profit scheme and obtain a judgment requiring the perpetrator to take nothing and repay the insurer all of its expenses in defeating the claim.

Available as a paperback. Available as a Kindle book.

Rescission of Insurance – 2nd Edition

Newly updated and expanded, “Rescission of Insurance – 2nd Edition” provides the insurance coverage lawyer, policyholder lawyer and claims professionals with everything needed to understand and enforce the equitable remedy of rescission. Everyone involved in or with the business of insurance must understand that rescission is an equitable remedy as ancient as the common law of Britain. When the United States was conceived in 1776 the founders were concerned with protecting their rights under British common law. They adopted it as the law of the new United States of America modified only by the limitations placed on the central government by the U.S. Constitution approved in 1789.

The viability and ability to enforce contracts was recognized as essential to commerce. Courts of law were charged with enforcing legitimate contracts. Courts of equity were charged with protecting contracting parties from mistake, fraud, misrepresentation and concealment since enforcing a contract based on mistake, fraud, misrepresentation or concealment would not be fair. The common law developed rules that courts could follow to refuse to enforce the terms of a contract that was entered into because of mutual mistake of material fact, a unilateral mistake of material fact, the breach of warranty (a presumptively material promise to do or not do something), a material concealment, or a material misrepresentation. The remedy – called rescission – created a method to apply fairness to the insurance contract and allow an insurer to void a contract and allowed courts to refuse to enforce such a contract entered into by misrepresentation or concealment of material facts.

Available as a paperback. Available as a Kindle book.

The Law of Unintended Consequences and the Tort of Bad Faith

The concept of unintended consequences is one of the building blocks of economics. Adam Smith’s “invisible hand,” the most famous metaphor in social science, is an example of a positive unintended consequence.

Most often, however, the law of unintended consequences illuminates the perverse unanticipated effects of legislation and regulation. In 1692 the English philosopher John Locke, a forerunner of modern economists, urged the defeat of a parliamentary bill designed to cut the maximum permissible rate of interest from 6 percent to 4 percent. Insurance is controlled by the courts, through appellate decisions, and by governmental agencies, through statute and regulation. Compliance with the appellate decisions, statutes, and regulations—different in the various states—is exceedingly difficult and expensive.

The business of insurance is, unfortunately, subject to the law of unintended consequences as if it were on steroids.

Available as a paperback Available as a Kindle book

Over the last 51 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.

“Construction Defects and Insurance”

The Structure, The Construction Contract, and Construction Defect Insurance Barry Zalma has updated and re-edited his seminal work Construction Defects Coverage Guide into is the latest addition to Barry Zalma’s insurance claims series of books and articles that will form the most thorough, up-to-date, expert-authored insurance claims guide available today eight Kindle or Paperback Volumes at reasonable prices.

Thorough, yet practical, this series of books form the ideal guide for any professional who works in or frequently interacts with the insurance industry.

Claims professionals, risk managers, producers, underwriters, attorneys (both plaintiff and defense), and business owners will benefit greatly from the ten-volume guide. It is also the perfect resource for insurance educators, trainers, and students whose role requires an understanding of insurance law.

The Eight volumes include:

Volume One: The Structure, The Construction Contract, and Construction Defect Insurance

Volume Two: The Defects and understanding Insurance and Underwriting 

Volume Three: Construction Defect Policies 

Volume Four: Liability Insurance

Volume Five: The Tort of Bad Faith and Construction Defects 

Volume Six: Construction Defect Suits

Volume Seven: Tort Defenses and the Trial of a Construction Defect Case

Volume Eight: Evaluation and Settlement & Alternative Dispute Resolution

"Heads I Win, Tails You Lose”

A collection of columns originally published in the magazines “Insurance Journal,” “Insurance Week,” and “The John Cooke Insurance Fraud Report” insurance trade publications serving the insurance community in the United States that have been updated and revised.

The title, “Heads I Win, Tails You Lose” is meant to describe insurance fraud as it works in the Unites States. It means that whenever a person succeeds in perpetrating an insurance fraud everyone who buys insurance is the loser.

“Insurance Fraud”

How Lawyers & Claims People Defeat Insurance Fraud

In Two Volumes

Insurance fraud continually takes more money each year than it did the last from the insurance buying public. No one knows the actual amount with any certainty because most attempts at insurance fraud succeed. Estimates of the extent of insurance fraud in the United States range from $87 billion to more than $300 billion every year. No one will ever be able to place an exact number on the amount lost to insurance fraud. Everyone who has looked at the issue knows – whether based on their heart, their gut or empirical fact determined from convictions for the crime of insurance fraud – that the number is enormous.

Volume One available as a Kindle book and a paperback.

Volume Two Available as a Kindle book and a paperback

“The Compact Book of Adjusting Property Insurance Claims – Second Edition”

A Manual for the First Party Property Insurance Adjuster

The insurance adjuster is not mentioned in a policy of insurance. The obligation to investigate and prove a claim falls on the insured. Standard first party property insurance policies, based upon the New York Standard Fire Insurance policy, contain conditions that require the insured to, within sixty days of the loss, submit a sworn proof of loss to prove to the insurer the facts and amount of loss.

The Compact Book of Adjusting Property Claims – Second Edition: A Primer for The First Party Property Claims Adjuster.

The Second edition adds new material from 2018 and 2019, is easier to use and more compact than the original.

Available as a Kindle book. Available as a paperback.

“The Compact Book on Adjusting Liability Claims, Second Edition”

A Handbook for the Liability Claims Adjuster

This Compact Book of Adjusting Liability Claims Second Edition: A Handbook for the Liability Claims Adjuster provides the new adjuster with a basic grounding in what is needed to become a competent and effective insurance adjuster. It is also available as a refresher for the experienced adjuster. Available as a Kindle book Available as a paperback.

Read about these and other insurance books by Barry Zalma at https://zalma.com/blog/insurance-claims-library/

Excellence in Claims Handling Courses From Experfy.com

The Excellence in Claims Handling program provides everything a person or entity presenting a claim needs to effectively present the claim and provides the insurance claims person with everything he or she needs to properly represent the insurer.

The insured, risk manager, or corporate counsel will be able to present a first party property claim - whether a fire, theft, or windstorm or some other insured against cause - with little difficulty and professionalism and present a sworn proof of loss acceptable to an insurer.

The insurance claims person completing the course will be able to conduct a thorough investigation of the policy and claim. The insurance claims person will also be able to assist an insured to fulfill all of the promises made by the insured to the insurer and the insurer to provide the indemnity promised by the insurance policy.

The series of courses was designed so that the student can obtain the needed information easily while he or she sits down in the morning for a first cup of coffee or any other time in the day in short, easy to consume lessons. For instance, “Insurance and Claims” is made up of three modules and 27 lectures while “Investigating the Property Claim” is made up of four modules and 65 lectures. You can review each course, each module and each lecture at the links below.

Each person completing the course will be able to claim that he or she is a professional first party property claims person ready to provide excellence in claims handling and be ready to resolve any claims problem that arises for the benefit of the insurer and the policy holder.

A key to every insurance claim is the thorough investigation required by law where the insurer’s adjuster or claims person works with the insured or his, her or its representative, to gather sufficient facts to determine the cause and origin of the claimed loss, whether the loss was due to a cause, the risk of loss of which was insured, and if so to determine the extent of the loss and the indemnity owed by the insurer to the insured.

https://www.experfy.com/training/courses

What will students need to know or do before starting this course?

That they want to know how to understand insurance and how the law applies to insurance contracts.

The course is capable of providing information needed without the assistance of material or software. However, it can be supplemented by books written by the author and available at https://www.zalma.com/blog/insurance-claims-library/ with materials like The Homeowners Insurance Policy, Zalma on Insurance Claims - ten Volumes, Construction Defects and Insurance, Mold Claims, and “Insurance Fraud & Weapons to Defeat Insurance Fraud,” The Compact Book of Adjusting Property Insurance Claims-Second Edition; Construction Defects and Insurance (eight volumes); Mold Claims (four volumes); Ethics for the Insurance Professional; Rescission of Insurance; The Insurance Examination Under Oath; Zalma on Property and Casualty Insurance; Insurance Law Deskbook; Insurance Bad Faith and Punitive Damages Deskbook; The Commercial Property Insurance Policy Deskbook; The Insurance Fraud Deskbook; Diminution in Value Damages; and Property Investigation Checklists Uncovering Insurance Fraud, 12th Edition.

 Who should take this course? Who should not?

The course should be taken by risk managers, corporate counsel, insurance claims management, insurance claims executives, insurance claims adjusters, insurance claims representatives, insurance special investigation unit investigators, public insurance adjusters, insurance coverage lawyers, insurance paralegals, and claims personnel of insurance agencies or insurance brokerages.

Insurance and Claims:  https://www.experfy.com/training/courses/insurance-and-claims

Investigating the Property Claims: https://www.experfy.com/training/courses/investigating-the-property-claim

Insurance Law: https://www.experfy.com/training/courses/insurance-law

Solving Claims Problems: https://www.experfy.com/training/courses/solving-claims-problems

Zalma’s Insurance 101 & Zalma on Insurance

A Free, Painless and Thorough Insurance Video Information and Training Program

I have completed 1024 videos dealing with the matters covered in my book “Insurance Claims: A Comprehensive Guide” that has been updated into a ten-volume edition now called “Zalma on Insurance Claims” available at amazon.com with details at the Insurance Claims Library.

Go to the Insurance Claims Library https://zalma.com/blog/insurance-claims-library/.

The purpose of this videoblog is to create a complete insurance claims education in three to four-minute increments. It was created to allow the student – whether a novice or experienced insurance professional – to learn painlessly by viewing one or more video a day, five days a week, 50 weeks a year. The videos will provide anyone interested in insurance to painlessly learn everything there is to know about property and casualty insurance claims while having the morning’s first cup of coffee or while munching on the first bagel of the day.

Zalma on Insurance Videos

Description Zalma on Insurance

 Over the last 52 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created a library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals available at https://zalma.com/blog/insurance-claims-library/. My original channel does not allow me to add posts so I have created a new channel, Barry Zalma available at Zalma on Insurance Videos where I post a new video almost every day.

 The latest videos deal with the tax consequences of a punitive damages award, the creation and application of the duty to defend including a total of 41 video. Please subscribe to the YouTube Channel and to my blog.

 I intend to post at this channel videos dealing with the insurance, insurance claims handling, the covenant of good faith and fair dealing, insurance litigation, interesting decisions of the courts of appeal dealing with insurance and the interpretation of an insurance policy. Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves as an arbitrator or mediator for insurance related disputes. (c) 2020, ClaimSchool, Inc.