ZALMA’S INSURANCE FRAUD LETTER December 1, 2020

A ClaimSchool? Publication ? 2020, Barry Zalma & ClaimSchool, Inc., Go to my blog & Videos at: Zalma on Insurance And at https://zalma.com/blog  Go to the Insurance Claims Library, Listen to the Podcast: Zalma on Insurance, Videos from Zalma on Insurance, Volume 24, Issue 23 – December 1, 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”  Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921

 Quote of the Issue

“We don’t stop playing because we grow old; we grow old because we stop playing.”

George Bernard Shaw

Evidence of A Prior Fire Is Available to Prove Fraud

Arson for Profit Conviction Affirmed

Evidence that is “inextricably intertwined” with the charged arson conspiracies is admissible in an arson for profit trial especially when the earlier fire was used as a “playbook” for the fire that is the subject of the appeal.

In United States Of America v. James Edward Lester, a/k/a Punkin, No. 19-4333, United States Court Of Appeals For The Fourth Circuit (June 9, 2020) a jury convicted James Lester of arson conspiracy, in violation of 18 U.S.C. § 844(m) (2018), money laundering conspiracy, in violation of 18 U.S.C. § 1956(h) (2018), mail and wire fraud conspiracy, in violation of 18 U.S.C. §§ 1349, 1341, 1343 (2018), arson to commit wire fraud, in violation of 18 U.S.C. § 844(h)(1) (2018), aiding and abetting an unlawful monetary transaction, in violation of 18 U.S.C §§ 2, 1957 (2018), and structuring transactions, in violation of 31 U.S.C. §§ 5324(a)(3), (d) (2018). He received a 204-month sentence.

Lester contended that the district court abused its discretion in admitting the evidence of a prior arson fire (the “Wharncliffe fire”) evidence. The district court admitted the evidence as intrinsic to the charged crimes. Alternatively, the district court determined that the evidence was admissible, pursuant to Fed. R. Evid. 404(b), as probative of Lester’s motive, knowledge, and intent.

Lester challenged the district court’s admission of the Wharncliffe fire evidence as intrinsic to the fraud charges, and he argued that the story of the crime was complete in itself and that there was no need to introduce evidence of the Wharncliffe fire. Lester also argues that the prejudicial effect of the Wharncliffe fire evidence substantially outweighed any probative value it may have had to prove the criminal nature of the fires that occurred at properties owned by the coconspirators in Matoaka and Ikes Fork, West Virginia. The Government contended that the district court properly admitted the Wharncliffe fire evidence as direct evidence of the Matoaka and Ikes Fork schemes because the evidence was intrinsic to the charged conspiracies.

Rule 404(b) applies only to evidence of other acts that are extrinsic to the one charged. Acts intrinsic to the alleged crime do not fall under Rule 404(b)’s limitations on admissible evidence.

Evidence is intrinsic if it is necessary to complete the story of the crime on trial. Other criminal acts are intrinsic when they are inextricably intertwined or both acts are part of a single criminal episode or the other acts were necessary preliminaries to the crime charged. Such evidence is inextricably intertwined with the evidence regarding the charged offense if it forms an integral and natural part of the witness’s accounts of the circumstances surrounding the offenses for which the defendant was indicted.

The Fourth Circuit, therefore, concluded that the district court did not abuse its discretion in admitting the Wharncliffe fire evidence as intrinsic to the charged conspiracies. This evidence laid the foundation for the arson and insurance fraud schemes, and it was necessary to complete the story of Lester’s relationships with his coconspirators. Moreover, the Wharncliffe fire evidence was “inextricably intertwined” with the charged arson conspiracies because the Wharncliffe fire was used as a “playbook” for the Matoaka and Ikes Fork fires.

In fact, the Wharncliffe fire insurance claim contents list was overwhelmingly similar to those of the Matoaka and Ikes Fork fire claims.

The district court’s judgment was affirmed.

ZIFL OPINION

Arson for profit is the most dangerous and vicious form of insurance fraud. Often firefighters or innocent neighbors are injured or killed by an arson fire. In this case the defendant had tried fraud with a fire before working with co-conspirators to set two more fires making claim for the destruction of the same property involved in the earlier fire. That fact made the evidence of the earlier fire – the Wharncliffe fire – inextricably intertwined with the fires for which he was tried and convicted.

 2020 Canadian Insurance Fraud Report

Fighting Fraud in the Pandemic Era

From Insurance Canada, good news: the desire to fight insurance fraud is getting stronger. In past studies, respondents gave fraud fighting a priority of 7/10, according to FRISS, but this year it scores closer to 8/10.

At the same time, fraudsters are watching for the “gaps” as insurers focus on their digital transformation.

With input from nearly 500 insurance professionals worldwide, the 2020 Insurance Fraud Report reveals:

• 75% saw an increased workload due to COVID and 43% were forced to reduce costs;
• 65% of insurers are focusing on digitalization;
• While 10% is the industry-standard “assumption” of the amount of claims that contain an element of fraud, this year’s responses averaged 18%;
• Data has been a top challenge for insurers for three surveys in a row.

Industry thought leaders expect an increase in fraud over the next 12 months. Insurers are looking for improvements through new or improved fraud fighting tools. This report sheds light on how insurers can drive digital change safely and in a sustainable way with a focus on industry trends and the impacts of COVID-19.

Minnesota Fraud Bureau:

Insurance Fraud Referrals Up In 2019

From the Minnesota Fraud Bureau reports were provided that Minnesota insurance regulators saw an uptick in the number of fraud case referrals during 2019, agent and broker fraud referrals down significantly that year, the most recent for which insurance fraud statistics for the state are available.

In its annual report for the year 2019 published on November. 16, 2020, the Minnesota Commerce Fraud Bureau (CFB) shows a 57 percent increase in total case referrals over the past five years and a 14 percent increase between 2018 and 2019. A total of 3,236 cases were referred to the CFB during 2019.

The CFB is Minnesota’s primary law enforcement agency responsible for conducting criminal investigations into cases involving insurance fraud and related criminal activity. It is the sixth largest law enforcement agency in the U.S. focused on insurance fraud investigations. California is first with 283 full-time law enforcement officers followed by Florida with 112, North Carolina with 40, Virginia with 25, West Virginia with 23 and Minnesota with 16.

The five largest areas of suspected fraud reported to the bureau during 2019 were:

• automobile insurance
• health Insurance
• homeowners insurance
• workers’ compensation insurance
• agent and broker fraud

There were 106 cases of agent/broker fraud referred to the CFB in 2019, a 41% decrease year-over-year from 2018. There were 151 agent/broker fraud cases referred to the CFB in 2015; 196 in 2016; 164 in 2017; and 181 in 2018.

The types of criminal action tracked by the CFB include senior scams, identification theft, medical ID theft, fraudulent health insurance claims, businesses illegally trying to avoid paying workers’ compensation premiums, cyber-crimes, property casualty insurance schemes and funeral insurance fraud.

In total, fraud bureau investigations that resulted in state and federal criminal charge filings had an economic impact of $29,252,691 in 2019.

Typically, the CFB gets case referrals from the general public, insurance companies, law enforcement agencies, and other governmental regulatory agencies

Overall, case referrals increased by 13% in 2019 compared with 2018. Over the five-year span of 2015 to 2019, total case referrals to the CFB increased by 57%.

Between 2015 to 2019, the number of auto insurance fraud cases referred to the CFB increased 146%; health insurance fraud decreased by 27%, with a 16% decrease between 2018 and 2019; and homeowners insurance fraud referrals grew by 118%,with a 44% spike between 2018 and 2019.

Reported workers’ comp insurance fraud cases also rose between 2015 and 2019, with a more than 16% increase from 2018 to 2019. There were 105 workers’ comp referrals in 2015, 101 in 2016, 120 in 2017, 129 in 2018, and 150 in 2019.

Due to the nature of insurance fraud investigations, the number of cases referred in a calendar year are separate from and independent of the number of cased charged or settled. In other words, cases investigated by the CFB can remain open and ongoing for more than one calendar year.

In 2019, CFB investigations resulted in the filing of 85 state and federal criminal charges against defendants. During the previous five-year period, the CFB obtained an average of 134 criminal charges against defendants annually. One of the largest cases investigated by the CFB in 2019 involved an auto insurance fraud scheme that resulted in convictions against a chiropractor and an attorney. Dubbed “Operation Back Cracker,” the long-term investigation uncovered a multi-million-dollar scheme perpetrated by chiropractors, attorneys and runners. Runners who worked for the chiropractors and attorneys steered people who had been either involved in a crash or staged a crash to collect auto insurance policy personal injury protection (PIP) benefits. In April 2019, the U.S. Attorney’s Office honored several members of the CFB with an award for Excellence in The Pursuit of Justice for their work on the Operation Back Cracker case.

ZIFL is pleased to learn that the CFB in Minnesota is receiving increased amounts of referrals but wonders why there are so few arrests and more importantly, convictions, are reported. A Fraud Bureau that does not obtain convictions for insurance fraud is merely making work for officers. Hopefully their conviction rate for 2020, with increased Covid fraud cases, will result in more convictions.

Wisdom

“We should be unfaithful to ourselves if we should ever lose sight of the danger to our liberties if anything partial or extraneous should infect the purity of our free, fair, virtuous, and independent elections.” — John Adams

“The trouble with the rat race is that even if you win, you’re still a rat.” — Lily Tomlin

“Republics are created by the virtue, public spirit, and intelligence of the citizens. They fall, when the wise are banished from the public councils, because they dare to be honest, and the profligate are rewarded, because they flatter the people, in order to betray them.” — Justice Joseph Story

“The Constitution ought to be the standard of construction for the laws, and that wherever there is an evident opposition, the laws ought to give place to the Constitution.” — Alexander Hamilton

Once we start to worry too often and too deeply about what certain individuals and what certain groups think about us, then we might start selling our souls for the sake of expediency.” —Otis Chandler

“A people who extend civil liberties only to preferred groups start down the path either to dictatorship of the right or the left.” —Justice William O. Douglas

 No Harm, No Foul When Instruction Error Favorable to Defendant

Podiatrist Jailed for Participation in Kickback Scheme Prescribing Compounded Medications Solely to Obtain Kickbacks

Dr. Alap Shah was convicted of participating in a Kickback scheme where he was paid for prescribing expensive compounded medications in United States of America v. Alap Shah, No. 19-12319, United States Court of Appeals for The Eleventh Circuit (November 24, 2020). He appealed the conviction based on what he and the government admitted was an erroneous instruction to the jury.

At the request of the government, the district court instructed the jury that Dr. Alap Shah violated the statute prohibiting kickbacks if one reason he accepted the payment was because it was in return for writing prescriptions. In his written briefs on appeal, Shah argued that the district court erred and should have instructed the jury that the government was required to prove that his main or only reason for accepting the payment was because it was made in return for writing prescriptions.

Both parties agreed at oral argument that the jury instruction was erroneous and that the statute requires no proof of the defendant’s motivation for accepting the illegal payment, so long as he accepts the kickback knowingly and willfully. The Issue presented to the Eleventh Circuit was whether the instruction prejudiced Shah.

BACKGROUND

Dr. Alap Shah was a podiatrist in Columbus, Georgia. He sometimes prescribed compounded medicines to his patients. Compounded medicines are custom-formulated drugs that can vary from off-the-shelf drugs in strength, delivery method, or combinations. For example, a compounded medicine might be a cream that combines three pain-reducing drugs ordinarily produced in pill form at a lower strength than available off the shelf. Specialized pharmacies produce compounded medicines, which are much more expensive than off-the-shelf prescription medications. A single tube of a compounded cream can cost $15,000 or more.

Shah and about 20 others participated in a kickback conspiracy that involved writing prescriptions for compounded drugs. Each of them faxed prescriptions for compounded drugs to a company called PGRx Group, which in turn directed a compounding pharmacy to fill the prescriptions. The pharmacy paid PGRx Group a kickback, usually around 50 percent of its profits, for each prescription PGRx Group referred to it. PGRx Group passed part of that kickback on to the prescribing doctor.

Shah received his share of the profits as a flat monthly payment of $5,000. PGRx Group disguised the nature of the payments by hiring the doctors to be “medical directors,” by calling the payments speaker fees for promoting PGRx Group and compounded drugs at professional events, and by routing payments to the prescribing doctors’ family members or employees.

Shah joined the conspiracy in May 2014 after being recruited by its masterminds, Paul Meek and Gary Small. Meek and Small offered him $5,000 each month for his participation. Shah corrected a typo in the contract from PGRx before signing it. The contract provided Shah’s duties as a medical director included performing on-site supervision and training, management, and administrative responsibilities. And the contract required PGRx Group to provide Shah with office space in its facility. Shah performed none of his duties under the contract. he did not even know where PGRx Group was located. And PGRx Group never provided him with office space. Regardless, PGRx Group always paid Shah $5,000 a month.

Shah prescribed compounded medications far more often after he signed the contracts with PGRx Group than before he signed the contract. At trial, Shah nevertheless insisted that he never wrote a prescription that a patient did not need.

Tricare, a federal program for members of the military and their families, paid for many of the prescriptions Shah wrote. It reimbursed at a higher rate than other insurance companies. Shah continued in this role until around May 2015, when Tricare made the conspiracy less profitable by instituting a prior-authorization requirement for compounded drugs. All told, he received checks from PGRx Group totaling $55,350.43. The prescriptions he wrote during the conspiracy cost Tricare more than a million dollars.

Shah’s closing argument focused on mens rea and the good-faith defense. He began by telling the jury that “[t]he case is about whether Dr. Shah acted willfully.” The jury convicted Shah. The district court sentenced him to 36 months of incarceration on each count, to run concurrently, and ordered him to pay $55,340 in restitution.

DISCUSSION

The statute on which he was convicted says nothing about the defendant’s motivation for accepting the payment. The text does not require proof of a defendant’s “purposes in soliciting or receiving” a payment. The statute’s key phrase—” remuneration . . . in return for [writing Tricare prescriptions]”—says nothing about the reasons the defendant accepted the payment. The Eleventh Circuit found no reason to stretch that phrase into a description of the defendant’s mental state. Congress specified the necessary mental state by requiring that the defendant must accept the payment “knowingly and willfully.”

To act “corruptly” means to act knowingly and dishonestly for a wrongful purpose. In the same way, the phrase “in return for” speaks to the nature of the payment, not Shah’s reasons for accepting it. The payor crime, which prohibits “knowingly and willfully offer[ing] or pay[ing] any remuneration . . . to induce” the same set of enumerated activities, prohibits payments that are meant by the payor to induce one of the enumerated actions. Motive matters for the payor crime even though it does not for the Dr. Shah’s payee crime.

The district court erred by instructing the jury that the government had to prove Shah accepted the payments at least in part because they were made in return for the prescriptions he wrote. No such proof was required. The government met its burden of proving beyond a reasonable doubt that the error did not harm Shah. The erroneous instruction required the government to prove more than the statute required, so if anything, the error worked to Shah’s advantage.

The district court correctly instructed the jury about the burden the government bore in proving willfulness. And it correctly instructed the jury that Shah committed no crime if he accepted the payments in good faith.

Shah’s own closing argument focused on the mens rea requirements and the good-faith instruction. Adding an unnecessary “one purpose” instruction could not have prejudiced Shah by detracting from the otherwise correct willfulness and good-faith instructions. In the absence of any prejudice to Shah, the conviction was affirmed.

ZIFL OPINION

This is a classic case of a convicted criminal claiming that his conviction should be reversed because of an erroneous instruction. The problem for Dr. Shah was that the erroneous instruction placed a higher burden on the prosecution than a correct instruction. The jury convicted him because the government proved his criminal conduct beyond a reasonable doubt even though the erroneous instruction made the job of proving the crime more difficult. No harm, no foul, go directly to jail and do not collect $200.00.

Good News From the Coalition Against Insurance Fraud

Latisha Harron lived large off Medicaid, pretending her home health firm gave needed care for lower-income residents of North Carolina. In fact, she ran a fake firm that tried to steal nearly $14 million from the state’s Medicaid program. Taxpayer money flowed from bogus home-health claims. Harron and her husband owned a British Aerospace Bae 125-800A Aircraft … Aston Martin sports car … Ford F-150 Super-Crew pickup truck … and expensive properties in several states. Harron ran Agape Healthcare Systems in Roanoke Rapids, N.C. She scoured online obits to locate recently deceased North Carolinians. Using their names, DOBs and other info, Harron queried the Medicaid eligibility tool to see if the deceased was eligible for Medicaid during their life. Harron then back-billed NC Medicaid for up to a year of phony home health services that she supposedly gave while the residents were alive. Medicaid sent millions to Agape. Harron and her husband carried out the fraud via the internet from locations around the globe, including their corporate office building and penthouse condo in Las Vegas, a corporate office in North Carolina, and hotels and luxury resorts in and outside of the U.S. Harron pled guilty and awaits sentencing. Her hubby Timothy Mark Harron still faces federal charges.

An Iowa stand-up comic could sit in jail for up to five years for stealing disability payments. Dustin Ruzicka took more than $123,000 in benefits while earning over $164,000 selling Visalus weight loss products during the same timeframe. Meanwhile, on social media, Ruzicka showed off his BMW and claimed he retired in 2011 because of his financial success with Visalus. Ruzicka claimed on his disability paperwork that he had daily leg pain, and that his ability to walk, stand or sit was limited. However, these claims didn’t stop him from promoting or performing stand-up comedy. The feds were kind enough to sit in on one of his Cedar Rapids performances. They witnessed Ruzicka kneeling to wire sound equipment, climbing a ladder to prepare for his show, all while standing on his feet the entire time without having to take a break from the pain. No word on Ruzicka’s comic material, but the agents clearly didn’t find his bogus claims funny. He awaits sentencing.

Dr. Yolanda Hamilton falsified info used to make patients fraudulently appear eligible for home health services. The Harris County, Tex. woman owned and operated HMS Health and Wellness Center. She paid patients to receive home health services, which were often medically unnecessary or not provided. Hamilton also required home health agencies to pay illegal kickbacks, which Hamilton disguised as a “copay,” in exchange for Hamilton certifying and recertifying patients for home health services. She often refused to release the companies’ paperwork until she was paid her kickback. Hamilton made over $300,000 in the scheme. She was sentenced to 5 years in prison for her crimes.

Health Insurance Fraud Convictions

Opioid Manufacturer Purdue Pharma Pleads Guilty to Fraud and Kickback Conspiracies

Purdue Agrees to Pay or Forfeit More Than $5 billion

Purdue Pharma LP (Purdue) pleaded guilty November 24, 2020 in federal court in Newark, New Jersey, to conspiracies to defraud the United States and violate the anti-kickback statute.

Purdue pleaded guilty to an information charging it with three felony offenses: one count of dual-object conspiracy to defraud the United States and to violate the Food, Drug, and Cosmetic Act, and two counts of conspiracy to violate the Federal Anti-Kickback Statute.

Purdue admitted that it marketed and sold its dangerous opioid products to healthcare providers, even though it had reason to believe those providers were diverting them to abusers.” The company lied to the Drug Enforcement Administration about steps it had taken to prevent such diversion, fraudulently increasing the amount of its products it was permitted to sell. Purdue also paid kickbacks to providers to encourage them to prescribe even more of its products.

As part of the guilty plea, Purdue admitted that from May 2007 through at least March 2017, it conspired to defraud the United States by impeding the lawful function of the Drug Enforcement Administration (DEA). Purdue represented to the DEA that it maintained an effective anti-diversion program when, in fact, Purdue continued to market its opioid products to more than 100 health care providers whom the company had good reason to believe were diverting opioids. Purdue also reported misleading information to the DEA to boost Purdue’s manufacturing quotas. The misleading information comprised prescription data that included prescriptions written by doctors that Purdue had good reason to believe were engaged in diversion. The conspiracy also involved aiding and abetting violations of the Food, Drug, and Cosmetic Act by facilitating the dispensing of its opioid products, including OxyContin, without a legitimate medical purpose, and thus without lawful prescriptions.

Purdue also admitted it conspired to violate the federal Anti-Kickback Statute. Between June 2009 and March 2017, Purdue made payments to two doctors through Purdue’s doctor speaker program to induce those doctors to write more prescriptions of Purdue’s opioid products. Also, from April 2016 through December 2016, Purdue made payments to Practice Fusion Inc., an electronic health records company, in exchange for referring, recommending, and arranging for the ordering of Purdue’s extended release opioid products – OxyContin, Butrans, and Hysingla.

Under the terms of the plea agreement, Purdue agreed to the imposition of the largest penalties ever levied against a pharmaceutical manufacturer, including a criminal fine of $3.544 billion and an additional $2 billion in criminal forfeiture. For the $2 billion forfeiture, the company will pay $225 million within three business days following the entry of a judgment of conviction in accordance with the Plea Agreement. The department is willing to credit the value conferred by the company to state and local governments under the department’s anti-piling on and coordination policy if certain conditions are met.

Purdue has also agreed to a civil settlement that provides the United States with an allowed, unsubordinated, general unsecured bankruptcy claim for recovery of $2.8 billion to resolve its civil liability under the False Claims Act. Separately, the Sackler family has agreed to pay $225 million in damages to resolve its civil False Claims Act liability.

The criminal and civil resolutions, which were announced on Oct. 21, 2020, do not include the criminal release of any individuals, including members of the Sackler family, nor are any of the company’s executives or employees receiving civil releases.

On Nov. 17, 2020, the bankruptcy court in the Southern District of New York approved the financial terms of the global resolution with the company. The resolution includes the condition that the company cease to operate in its current form and instead emerge from bankruptcy as a public benefit company (PBC) or entity with a similar mission designed for the benefit of the American public. The proceeds of the PBC will be directed toward state and local opioid abatement programs. Based on the value that would be conferred to state and local governments through the PBC, the department is willing to credit up to $1.775 billion against the agreed $2 billion forfeiture amount. The department looks forward to working with the creditor groups in the bankruptcy in charting the path forward for this PBC to best accomplish public health goals.

The global resolution does not resolve claims that states may have against Purdue or members of the Sackler family, nor does it impede the debtors’ or other third parties’ ability to recover any fraudulent transfers.

Except to the extent of Purdue’s admissions as part of its criminal resolution, the claims resolved by the civil settlements are allegations only. There has been no determination of liability in the civil matters.

Former Most Wanted Fugitive Sentenced To 36 Months in Prison for Multi-Million Dollar Health Care Fraud

Former Co-Owner of Long Island Company Defrauded Medicare and Medicaid of Millions of Dollars for Medical Supplies Never Provided to Patients

Etienne Allonce, the former co-owner of Medical Solutions Management, Inc. (MSM), a durable medical equipment supplier in Hicksville, New York, was sentenced by United States Circuit Judge Joseph F. Bianco to 36 months’ imprisonment for health care fraud. The Court also ordered Allonce to pay $4,444,468 in restitution. Allonce pleaded guilty in April 2019. In September 2018, Allonce was expelled from Haiti where he had fled 11 years earlier shortly before his indictment in the Eastern District of New York. Prior to his return to the United States, Allonce was placed on the Most Wanted List of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG).

“Allonce ran, but ultimately could not hide from the consequences of fleecing Medicare and Medicaid out of millions of dollars at taxpayers’ expense,” stated Acting United States Attorney DuCharme. “The defendant may have delayed the inevitable, but he has now faced justice for breaking the law.”

Between April 2003 and March 2007, Allonce, and his wife and MSM co-owner Michel Allonce, submitted approximately $10 million in false claims to Medicare and Medicaid, seeking payment for medical supplies never ordered by MSM and never delivered to patients at nursing homes. Etienne Allonce fled the United States just hours before federal agents arrested his wife in 2007.

Michel Allonce was tried and convicted by a jury in August 2012. She was sentenced in April 2013 to 12 years’ imprisonment, and ordered to forfeit $1.3 million seized by the government. 

$5.8 Million To Settle False Claims Act Allegations

Doctor’s Choice Home Care, Inc. and its former owners, Timothy Beach and Stuart Christensen, have agreed to pay $5.15 million to resolve allegations that the home health agency provided improper financial inducements to referring physicians through sham medical director agreements and bonuses to physicians’ spouses who were Doctor’s Choice employees, the Department of Justice announced today.

Timothy Beach and Stuart Christensen founded Doctor’s Choice and formerly served as its top executives. Doctor’s Choice is a home health agency based in Sarasota, Florida, with branches throughout the state. 

Doctor’s Choice will pay $3,856,000 to settle these allegations and Beach and Christensen will each pay $647,000. Doctor’s Choice will pay an additional $675,000 to resolve separate allegations that employees pressured clinical personnel to increase the number of home visits for Medicare patients to avoid the Medicare Low Utilization Payment Adjustment that would have decreased the reimbursement Doctor’s Choice received from Medicare in the absence of these unnecessary services.

The Anti-Kickback Statute prohibits the offering or payment of remuneration to induce or reward referrals for services paid for by federal healthcare programs. The Stark Law forbids certain medical providers, including home health agencies, from submitting claims to Medicare for services provided to patients who were referred by a physician with whom the provider has a prohibited financial relationship, unless that relationship falls within an applicable exception.

This settlement resolves allegations that Doctor’s Choice, Beach, and Christensen violated the Anti-Kickback Statute and the Stark Law by entering into sham medical director agreements with physicians as a means of providing remuneration for referrals, and also violated the Stark Law by providing bonuses to employees based on referrals to Doctor’s Choice by the employees’ physician spouses. In addition, the agreement resolves allegations that Doctor’s Choice provided unnecessary services to Medicare patients in order to increase the number of skilled services provided during a home health visit to avoid the Low Utilization Payment Adjustment which otherwise would have decreased Doctor’s Choice Medicare reimbursement. This adjustment is triggered when a home health patient has a treatment episode consisting of less than five skilled service visits and results in the provider receiving a standardized per visit payment rather than the higher payment for a full home health episode. 

The allegations resolved in this settlement were originally brought in two lawsuits filed under the qui tam, or whistleblower, provisions of the False Claims Act; one case was filed by Corina Herbold and the second case was filed by Sara Billings, Misty Sykes, and Marina Eschoyez-Quiroga, all of whom are former employees of Doctor’s Choice. The Act permits private parties to sue on behalf of the government for false claims for government funds and to receive a share of any recovery. Billings, Sykes, and Eschoyez-Quiroga will jointly receive a share of approximately $145,000 arising from the government’s recovery for the Low Utilization Payment Adjustment allegations. Herbold’s share has not yet been determined.

$4.6 Million Health Care Fraud and Kickback Schemes Related to Genetic Testing

Edward B. Kostishion, 60, of Lakeland, Florida, pleaded guilty by videoconference before U.S. District Judge Brian R. Martinotti to a superseding information charging him with two counts of conspiracy to commit an offense against the United States in connection with schemes to commit health care fraud and violate the Anti-Kickback Statute. Kostishion and five co-defendants were previously charged by indictment in September 2019 in connection with these conspiracies.

According to documents filed in this case and statements made in court:

Kostishion and certain conspirators operated Ark Laboratory Network LLC (Ark), a company that purported to operate a network of laboratories that facilitated genetic testing. Ark partnered with Privy Health Inc., a company that another conspirator operated, and another company to acquire DNA samples and Medicare information from hundreds of patients through various methods, including offering $75 gift cards to patients, all without the involvement of a treating health care professional. Matthew S. Ellis, a physician based in Gainesville, Florida, and a co-defendant charged in the indictment, served as the ordering physician who authorized genetic testing for hundreds of patients across the country that he never saw, examined, or treated. These included patients from New Jersey and various other states where Ellis was not licensed to practice medicine. Through this process, Ellis, Kostishion, and other conspirators submitted and caused to be submitted fraudulent orders for genetic tests to numerous clinical laboratories. These orders falsely certified that Ellis was the patients’ treating physician and, in some cases, falsely indicated that a patient had a personal or family history of cancer. In 2018 alone, Medicare paid clinical laboratories at least $4.6 million for genetic tests that Ellis ordered as part of this scheme.

In addition, Kostishion and certain conspirators entered into kickback agreements with certain clinical laboratories under which the laboratories paid Ark bribes in exchange for delivering DNA samples and orders for genetic tests. Among other things, Ark concealed these kickback arrangements through issuing sham invoices to laboratories that purportedly reflected services provided at an hourly rate even though the parties had already agreed upon the bribe amount, which was based on the revenue the laboratories received from Medicare or an amount paid for each DNA sample. In 2018, the clinical laboratories paid Ark at least $1.8 million in bribes. 

Each conspiracy count carries a maximum penalty of five years in prison and a fine of $250,000, or twice the gross gain or loss from the offense. Kostishion’s sentencing is scheduled for April 1, 2021.

Co-defendants Kacey C. Plaisance, of Altamonte Springs, Florida, and Kyle D. McLean, of Arlington Heights, Illinois, previously pleaded guilty. Plaisance is scheduled to be sentenced on March 15, 2021. McLean is scheduled to be sentenced on April 12, 2021.

Former Owners of Therakos, Inc. Pay $11.5 Million

Johnson & Johnson (“J&J”) subsidiary Medical Device Business Services, Inc. (“MDBS”) agreed to pay $10 million to settle allegations under the False Claims Act that Therakos, Inc., a former J&J subsidiary, engaged in promotion of the UVAR XTS and CELLEX extracorporeal photopheresis (“ECP”) systems for unapproved uses in pediatric patients between 2006 and 2012. The Gores Group (“TGG”) agreed to pay an additional $1.5 million to resolve allegations that Therakos continued those alleged improper sales and promotion practices after TGG acquired Therakos from J&J in 2012.

In 1999, the Food and Drug Administration (“FDA”) approved UVADEX, the drug administered by the Therakos ECP systems, for “the palliative treatment of the skin manifestations of cutaneous T-cell lymphoma that is unresponsive to other forms of treatment.” Cutaneous T-cell lymphoma is a cancer of the immune system in which cancerous T-cells migrate to the skin, causing lesions. Therakos’s ECP drug/device systems administer the medication UVADEX (methoxsalen) by first removing a portion of the patient’s blood and separating the red blood cells from the white blood cells by using a centrifuge. The red cells are returned to the patient and the UVADEX solution is combined with the white cells. The device then irradiates the drug-cell mixture with ultraviolet light and returns the treated cells to the patient.

The government alleged that between 2006 and 2015, Therakos marketed and promoted its ECP systems to treat pediatric patients for indications that were not approved by the FDA. At no time during this period were the ECP drug/devices approved by the FDA for use in the pediatric population. The government further alleges that Therakos’s improper promotion caused false claims to be submitted to three federal healthcare programs: Medicaid, the Federal Employee Health Benefits Program, and Tricare.

This settlement resolves a lawsuit filed under the whistleblower provision of the False Claims Act, which permits private parties to file suit on behalf of the United States for false claims and share in a portion of the government’s recovery. The civil lawsuit was filed in the Eastern District of Pennsylvania and is captioned United States ex rel. Johnson et al. v. Therakos, Inc. et al., No. 12-cv-1454. The qui tam complaint was filed by Brian McCormick of Ross Feller Casey LLP in Philadelphia, PA.

Business Owner Who Orchestrated $13 Million Fraud Pleads Guilty Forfeits Proceeds of Crime

Latisha Harron, also known as Latisha Reese Holt, 44, originally from Eastern North Carolina and now a Las Vegas, Nevada resident pleaded guilty November 18, 2020 to Conspiracy to Commit Health Care Fraud, Conspiracy to Commit Money Laundering, and Aggravated Identity Theft, and further agreed to forfeit the proceeds of her crimes. These proceeds included up to $13,396,921.64, a British Aerospace Bae 125-800A Aircraft, a 2017 Aston Martin DB 11 sports car; a 2016 Ford F-150 Super-Crew pickup truck; real property held in the name of Assured Healthcare Systems in Hertford County, North Carolina; real property located in Charles County, Maryland; as well as various other items of designer jewelry and luxury items seized from the defendant’s penthouse condominium in Las Vegas.

According to court documents Harron admitted to conspiring with her husband to carry out a massive fraud upon the North Carolina Medicaid Program (“NC Medicaid”) by billing the government for fictitious home health services. Harron admitted to then working with her husband to launder the proceeds of the fraud into, among other things, a private jet, luxury jewelry and clothing, and properties in Ahoskie and Rich Square, North Carolina.

According to the charges, Harron created, and was operating, Agape Healthcare Systems, Inc. (“Agape”) an alleged Medicaid home health provider, in Roanoke Rapids, North Carolina. As charged, to enroll Agape as a Medicaid provider, Harron fraudulently concealed her prior felony conviction for Identity Theft. In 2012, Harron moved out of North Carolina to Maryland. Despite that move, Harron continued to bill NC Medicaid as though Agape was providing home health services to North Carolina recipients.

As charged, in May of 2017, Latisha Harron moved to Las Vegas, Nevada to live with codefendant Timothy Mark Harron, and that the two were married in 2018. The indictment alleges that Timothy Harron was also a previously convicted felon, and that this fact was concealed from the NC Medicaid on enrollment documents. Harron pleaded guilty to allegations that Harron and her husband then worked together to expand the Agape fraud upon NC Medicaid, by fraudulently billing the program for more than $10 Million, just in the period between 2017 and 2019. 

As charged, Harron admitted that she and her husband carried out the fraud by exploiting an eligibility tool that was entrusted only to NC Medicaid providers. Specifically, Harron and her husband searched publicly available sources, such as obituary postings on the internet by North Carolina funeral homes, to locate recently deceased North Carolinians. Harron admitted that the two would then extract from the obituary postings certain personal information for the deceased, including their name, date of birth, and date of death. Then, utilizing the extracted information, the defendants would then query the NC Medicaid eligibility tool to determine whether the deceased individual had a Medicaid Identification Number. If the deceased North Carolinian had a valid Medicaid Identification Number and was otherwise eligible for Medicaid coverage during their life, the defendants would use that individual’s identity to “back-bill” NC Medicaid, through Agape, for up to one year of fictitious home health services that were allegedly rendered prior to the death of the individual. NC Medicaid then disbursed millions to Agape, all of which flowed into accounts controlled by the Harron and her husband.

Harron admitted that she and her husband carried out the fraud via the internet from locations around the globe, including their corporate office building in Las Vegas, their penthouse condominium in Las Vegas, a corporate office in North Carolina, and from various hotels and luxury resorts in and outside of the United States.

Harron further pled guilty to laundering the proceeds of the Agape fraud into various luxury items. These expenses included a $900,000 wire for the purchase of a British Aerospace Bae 125-800A private jet, hundreds of thousands of dollars in Tiffany & Co. and Brioni clothing and jewelry, thousands of dollars on Eastern North Carolina business properties, and thousands of dollars in gym equipment.

Latisha Harron pleaded guilty to (1) Conspiracy to Commit Health Care Fraud and Wire Fraud, in violation of Title 18, United States Code, Section 1349, which carries a maximum punishment of up to 20 years in prison, (2) one count of Aggravated Identity Theft, in violation of Title 18, United States Code, Section 1028A, each of which carry a maximum punishment of not less than, nor more than, 2 years in prison consecutive to other sentences, and (5) Conspiracy to Commit Money Laundering, in violation of Title 18, United States Code, Section 1956(h), which carries a maximum punishment of 10 years in prison.

The success of the fraud is made clear by the valuable that will be turned over to the government. Rather than having the dead vote they made a fortune letting the dead make claims to Medicare and other governmental health plans. ZIFL can only wonder why the defendants were able to live a life of luxury for 8 years before the government caught on to their crime.

Guilty of Defrauding State Medicaid Agency Of At Least $1.5 Million

Heidi Robertson, 35, was employed as the primary insurance biller at a Birmingham-area psychology clinic that billed the Medicaid Agency for counseling services that were never provided.

Robertson was sentenced to 18 months in prison and ordered to pay $850,000 in restitution by U.S. District Judge R. David Proctor after she pleaded guilty earlier this year to one count of conspiracy to commit healthcare fraud by filing false claims to the Alabama Medicaid Agency for individual and group counseling services for at-risk youth while she was employed at Capstone Medical Resources LLC. The owner of the facility, former Birmingham psychologist Sharon D. Waltz, pleaded guilty in 2019 to defrauding Medicaid of at least $1.5 million. Waltz is scheduled to be sentenced by Judge Proctor on December 10.

An investigation was initiated by the Program Integrity Division of the Alabama Medicaid Agency after an audit showed that billings submitted by Capstone for counseling services had increased from $99,000 in 2015 to more than $2 million in 2017. The Program Integrity Division referred its findings to the Attorney General’s Medicaid Fraud Control Unit after Waltz submitted falsified records during the Program Integrity Audit.

A subsequent investigation was conducted by the Medicaid Fraud Control Unit and the U.S. Department of Health and Human Services Office of Inspector General. This investigation determined that most claims submitted by Capstone from 2016 to 2018 were fraudulent. Robertson’s role in the scheme included submitting claims using the Medicaid identifications of friends’ and family members’ children for counseling services that never took place. Waltz paid Robertson a 10 percent commission for all claims paid by Medicaid. Robertson was employed by Waltz from 2016 through late 2017.

Owner of Durable Medical Equipment Companies Admits Role In $16 Million Dollar Kickback Scheme

Albert Davydov, 28, of Rego Park, New York, pleaded guilty by videoconference before U.S. District Judge Kevin McNulty to an indictment charging him with conspiring to violate the Anti-Kickback statute.

Davydov, the owner of a group of related durable medical equipment (DME) companies admitted his role in a conspiracy to pay kickbacks in exchange for durable medical equipment on November 13, 2020.

According to documents filed in this case and statements made in court: Davydov, the owner of nine DME companies, participated in a scheme to pay kickbacks in exchange for doctors’ orders for medically unnecessary orthotic braces. Once Davydov and his conspirators received the completed doctor’s orders, they billed Medicare and other federal and private health care benefit programs for the braces. Davydov concealed his ownership of the DME companies by falsely reporting to Medicare that various straw owners owned the companies. 

As part of his plea agreement, Davydov agreed that the improper benefit conferred was over $16 million for the charged conspiracy to violate the federal Anti-Kickback statute. The conspiracy charge to which Davydov pleaded guilty carries a maximum penalty of five years in prison and a fine of $250,000, or twice the gross grain or loss from the offense, whichever is greatest. Sentencing is scheduled for March 25, 2021.

Texas Man Sentenced to Prison for Fraudulently Billing Government Medical Insurance Programs

Prosecution Is Part of Effort Against Fraudulent ‘Telehealth’ Scams

Patrick Siado, 39, of Houston, was sentenced to 51 months in federal prison and ordered to pay $50,075 in restitution by U.S. District Court Chief Judge J. Randal Hall after pleading guilty to one count of Conspiracy. After completion of his prison sentence, Siado must serve three years of supervised release.

As described in court documents and testimony, Siado admitted that he and unindicted co-conspirators hired individuals to solicit information and take DNA swabs from low-income and elderly residents. The individuals were paid $150 for each “patient,” with the information used by other conspirators to submit fraudulent claims to Medicare and Medicaid. Siado would then receive an illegal kickback ranging from $100 to $575 per test accepted for billing, which typically generated a claim to Medicaid of more than $30,000 each.

The Southern District of Georgia has now charged 30 individuals and companies as part of the nationwide crackdown on fraudulent genetic testing, and prescribing of orthotic braces and pain creams, identifying more than $1.5 billion in losses to Medicare and Medicaid.

Inglewood Women Plead Guilty to Running Scheme to bill Medi-Cal For Substance Abuse Counseling

Mesbel Mohamoud, 47, and her mother-in-law, Erlinda Abella, 66, also of Inglewood, pleaded guilty to one count of health care fraud in separate hearings before United States District Judge Philip S. Gutierrez.

The Inglewood, California woman and her mother-in-law, who both ran a South Los Angeles drug and alcohol abuse treatment program, each pleaded guilty today to a health care fraud charge for fraudulently submitting more than $500,000 in claims for services that did not qualify for reimbursement or were never provided.

Mohamoud was the owner and executive director of The New You Center Inc. (TNYC), located in the Vermont Knolls neighborhood of South Los Angeles. Abella, who co-founded TNYC with Mohamoud in 2005, was the company’s program director. TNYC had contracts to provide medically necessary substance abuse treatment services through the Drug Medi-Cal program to adults and teenagers in Los Angeles County.

According to Mohamoud’s and Abella’s plea agreements, from January 2009 to December 2015, TNYC submitted false and fraudulent bills for counseling sessions that were not conducted at all, were not conducted at authorized locations, or did not comply with Drug Medi-Cal regulations regarding the length of sessions or the number of clients.

Mohamoud and Abella also allegedly caused TNYC to bill for clients who did not have a substance abuse problem, to falsify documents related to services supposedly provided to clients, and to forge client signatures on documents such as sign-in sheets.

For example, in September 2013, TNYC submitted a fraudulent claim for Medi-Cal reimbursement in the amount of $62.15 for a three-hour counseling session for a client on August 17, 2013 – the same day when the client was hospitalized and did not receive any counseling from TNYC.

In court documents, Mohamoud further admitted she knew that among the acts Abella directed TNYC counselors to engage in included enrolling clients in TNYC’s substance abuse treatment program even if the clients had used drugs or alcohol only occasionally or even just once.

Mohamoud and Abella admitted that TNYC submitted approximately $527,313 in false and fraudulent claims for group and individual substance abuse counseling services and was paid $260,101 on those claims.

Texas Physician Sentenced to Five Years for Multi-Million Medicare Fraud Scheme

Yolanda Hamilton, M.D., 57, of Harris County, Texas, the physician-owner and operator of HMS Health and Wellness Center, PLLC, was sentenced by U.S. District Judge Keith P. Ellison of the Southern District of Texas. Judge Ellison also ordered the defendant to pay $9.5 million in restitution.

Hamilton, a Texas physician was sentenced to five years in prison November 18, 2020 for her role in a multi-million Medicare fraud scheme. 

Hamilton was convicted by a federal jury of one count of conspiracy to commit health care fraud, one count of conspiracy to solicit and receive health care kickbacks, and two counts of false statements relating to health care matters in October 2019. According to the evidence presented at trial, from January 2012 to August 2016, Hamilton conspired with others to defraud Medicare by signing false and fraudulent home healthcare paperwork that was used to submit fraudulent claims to Medicare. 

Hamilton and her co-conspirators made it appear that the patients qualified and received home healthcare services, when they often did not. In fact, members of the conspiracy paid the patients to receive the home healthcare services, which were often medically unnecessary, not provided, or both. The evidence also showed that Hamilton required home healthcare agencies to pay an illegal kickback, which Hamilton disguised as a “co-pay,” in exchange for Hamilton certifying and recertifying patients for home healthcare services. 

Hamilton typically would not release the home healthcare paperwork until the home healthcare companies or their marketers paid her the kickback, the evidence showed. The scheme resulted in approximately millions in false and fraudulent claims for home-health services to Medicare and in Hamilton receiving over $300,000 in kickbacks.

All defendants are presumed innocent until convicted beyond a reasonable doubt in a court of law.

To date, several co-conspirators including marketers, patient recruiters along with doctors, and nurses who purchased plans of care and other signed medical documents from Hamilton have been charged, found guilty, or pleaded guilty to conspiracy to commit health care fraud and/or paying or receiving kickbacks.

Medicare Advantage Provider to Pay $6.3 Million To Settle False Claims Act Allegations

Kaiser Foundation Health Plan of Washington, formerly known as Group Health Cooperative (GHC), agreed to pay $6,375,000 to resolve allegations that it submitted invalid diagnoses to Medicare for Medicare Advantage beneficiaries and received inflated payments from Medicare as a result, the Justice Department announced today. Kaiser Foundation Health Plan is headquartered in Oakland, California.

Under the Medicare Advantage program, also known as Medicare Part C, Medicare beneficiaries may opt to obtain health care coverage through private insurance plans that are owned and operated by private insurers known as Medicare Advantage Organizations (MAOs). Medicare pays MAOs a fixed, monthly amount to provide health care coverage to Medicare beneficiaries who enroll in their plans. Medicare adjusts these monthly payments to reflect the health status of each beneficiary. In general, Medicare pays MAOs more for sicker beneficiaries and less for healthier ones.

MAOs report beneficiary diagnoses and other information to Medicare on an annual basis and Medicare uses this information to adjust the payments that the MAO receives from Medicare. The settlement resolves allegations that GHC knowingly submitted diagnoses that were not supported by the beneficiaries’ medical records to inflate the payments that it received from Medicare.

The settlement resolves allegations originally brought in a lawsuit filed under the qui tam, or whistleblower, provisions of the False Claims Act by Teresa Ross, a former employee of Group Health. The act permits private parties to sue on behalf of the government for false claims for government funds and to receive a share of any recovery. Former Employee of Birmingham Area Psychology

Clinic Sentenced for Role in Defrauding State Medicaid Agency of at Least $1.5 Million

Heidi Robertson, 35, was employed as the primary insurance biller at a Birmingham, Alabama-area psychology clinic that billed the Medicaid Agency for counseling services that were never provided. Robertson was sentenced November 17, 2020 for her role in a scheme to defraud the Alabama Medicaid Agency of at least $1.5 million to 18 months in prison and ordered to pay $850,000 in restitution by U.S. District Judge R. David Proctor after she pleaded guilty earlier this year to one count of conspiracy to commit healthcare fraud by filing false claims to the Alabama Medicaid Agency for individual and group counseling services for at-risk youth while she was employed at Capstone Medical Resources LLC. The owner of the facility, former Birmingham psychologist Sharon D. Waltz, pleaded guilty in 2019 to defrauding Medicaid of at least $1.5million. Waltz is scheduled to be sentenced by Judge Proctor on December 10.

An investigation was initiated by the Program Integrity Division of the Alabama Medicaid Agency after an audit showed that billings submitted by Capstone for counseling services had increased from $99,000 in 2015 to more than $2 million in 2017. The Program Integrity Division referred its findings to the Attorney General’s Medicaid Fraud Control Unit after Waltz submitted falsified records during the Program Integrity Audit.

A subsequent investigation was conducted by the Medicaid Fraud Control Unit and the U.S. Department of Health and Human Services Office of Inspector General. This investigation determined that most claims submitted by Capstone from 2016 to 2018 were fraudulent. Robertson’s role in the scheme included submitting claims using the Medicaid identifications of friends’ and family members’ children for counseling services that never took place. Waltz paid Robertson a 10 percent commission for all claims paid by Medicaid. Robertson was employed by Waltz from 2016 through late 2017.

Psychiatrist Pleads Guilty to Federal Health Care Fraud Charge

Uzma Ehtesham, a Wise, Virginia psychiatrist who defrauded Virginia Medicaid and Medicare by fraudulently billing these programs for services, pleaded guilty November 5, 2020 to federal health care fraud.

Ehtesham, 52, waived her right to be indicted and pleaded guilty to a one-count Information charging her with health care fraud.

According to court documents, from 2010 to 2016, Ehtesham devised a scheme to defraud Virginia Medicaid and Medicare by billing for individual office visits when she often saw patients in groups of two to four patients per visit.

In addition, Ehtesham billed for extensive, time consuming, and costly office visits when she was conducting brief office visits consisting of five to six minutes and billed for services not supported by required documentation.

During the time of the investigation, Ehtesham was seeing in excess of 50 patients per day. Often, prescriptions were written in advance of a scheduled visit by the office staff, placed in patient files, and signed by Ehtesham during the brief patient visit. At times, Ehtesham did not employ any medically certified staff to compile patient’s vital statistics at each visit. Instead, vital statistics were copied from previous patient visits to each new visit information sheet at Ehtesham’s direction.

As part of the scheme to defraud, Ehtesham received $500,000 in fraudulently obtained payments processed from Virginia Medicare and Medicaid. As part of the plea agreement, Ehtesham is required to pay a total of $1,000,000, consisting of restitution, fines, and forfeiture.

A sentencing hearing has been scheduled for January 28, 2021, at 2:30 p.m.

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

Federal Contractor Agrees to Pay $18.98 Million For Alleged False Claims Act

Cognosante LLC has agreed to pay the United States $18,987,789 to resolve allegations that it violated the False Claims Act by using unqualified labor and overcharging the United States for services provided to government agencies under two General Services Administration (GSA) contracts, the Justice Department announced today. Cognosante, which is headquartered in Falls Church, Virginia, provides health care and IT services and solutions to federal agencies.

GSA’s Multiple Award Schedule (MAS) contracts allow the federal government to leverage its buying power to achieve favorable pricing. Under MAS contracts, contractors negotiate with GSA to set maximum prices for goods and services subsequently ordered by agencies across the federal government. These contracts provide streamlined access to the federal marketplace.

The settlement resolves allegations that Cognosante overcharged the United States for services performed under two GSA MAS contracts, including by providing false information concerning Cognosante’s commercial discounting practices during contract negotiations. It also resolves allegations that Cognosante charged the United States for labor that failed to meet the qualifications in one of the contracts.

Retired Canton Police Officer Convicted of Workers’ Comp Fraud

James Blaine, of North Canton, Ohio, pleaded guilty to the fourth-degree felony charge of workers’ compensation fraud in Stark County Court of Common Pleas on November 19, 2020.

Blaine, a retired Canton police officer was convicted of workers’ compensation fraud after investigators found out he was working two jobs while claiming to be permanently disabled.

According to investigators with the Ohio Bureau of Workers’ Compensation, Blaine was working as a security guard for a private company and running his own landscaping business in 2017.

At the same time, Blaine was collecting permanent total disability benefits for an injury he suffered while working at a salt company.

Blaine has to pay the BWC over $66,000 in restitution and $23,000 in investigative costs. He was also ordered to three years of probation and 100 hours of community service.

The fraud was unrelated to Blaine’s job as a police officer, which he retired from in 1997.

Gwent Man Jailed After Fabricating Elaborate Household Fires in Bid for Insurance Payout

William James, 64 of Blackwood, Gwent, U.K. was sentenced to 16 months in prison after an appearance at Newport Crown Court on 13 November 2020. Mr. James previously pleaded guilty to these offences following a court hearing on 2 October 2020.

James was jailed after fabricating a string of elaborate household fires following a joint investigation between the Insurance Fraud Bureau (IFB) and South Wales Police.

Investigators were first made aware of Mr. James’ fraudulent activities following a tip off to the IFB, where it transpired a series of near-identical claims all following alleged household fires had been made under different names across Gwent county.

On four occasions, claims had been made for a ￡695 damaged wig believed to have been used for ‘karaoke nights’, after being knocked onto a lit burner. In at least three further instances, claims were made for gold rings that had been lost in the back of an ambulance following a fire rescue, which was confirmed by local authorities to have never taken place.

Several claims were also found to have been made for chip pans that had been catching fire and causing damage to kitchen interiors.

The IFB which is a not-for-profit organization that investigations organized insurance fraud, found Mr. James had created a series of fake identities and falsified invoices for lost and damaged goods to help enable his fraudulent activities. In total, four insurers were affected including Aviva, Direct Line Group and Zurich with all fraudulent claims collectively valued at around ￡60,000.

Currently at least one insurance scam takes place every minute in the UK, which is estimated to cost insurers and honest consumers ￡3 billion a year. Property fraud is a fast growing scam, with recent figures from the Association of British Insurers (ABI) showing dishonest claims for lost and damaged property rose 30% in 2019.

 N.Y. Woman Sentenced for Stealing More Than $3k In Workers’ Comp Benefits

Bonnie S. Slater of Randolph, N.Y., was sentenced in Cattaraugus County Court before Hon. Ronald Ploetz after pleading guilty in September to forgery in the third degree and petit larceny, both misdemeanors. She was ordered to pay $3,933.78 in restitution and costs.

Slater, a New York woman who stole $3,065.28 in workers’ compensation benefits by forging her late father’s name in order to cash the checks has been sentenced to one year in jail.

An investigation by New York State Inspector General Letizia Tagliafierro found that Slater’s father, Alan Slater, passed away on August 29, 2017. Slater later obtained and endorsed six workers’ compensation benefit checks intended for her father from September through November 2017.

Slater cashed the checks at a local supermarket after Alan Slater’s death. All checks were issued in the amount of $510.88. In total, Slater defrauded the workers’ compensation system by stealing $3,065.28 in benefits to which she was not entitled.

“By forging her deceased father’s signature on these checks, this individual illegally obtained workers’ compensation benefits,” Tagliafierro said in a press release issued by her office.

Unlicensed Broker Convicted the Second Time for Insurance Fraud

Rosie Villegas, 51, of North Hills, California pleaded no contest November 17, 2020 to one misdemeanor count of insurance fraud after failing to place auto insurance coverage for clients and misappropriating premium funds for her own personal use. Villegas was sentenced to three years of probation, 20 days of community service, and paid $1,169 in restitution. Villegas has a prior conviction from a similar crime in April 2017.

In her current case, the California Department of Insurance received a complaint in July 2017 from an alleged victim of Villegas and launched an investigation. The investigation revealed Villegas had sold an automobile insurance policy to the victim, but failed to place the coverage. Villegas’ actions left the victim uninsured and as a result they suffered an uninsured loss.

Further investigation found that Villegas sold another automobile insurance policy to another victim, in which she misrepresented their information on an insurance application and misappropriated $1,169 in premium funds for her own personal use. The victim was unaware that the misrepresentation took place.

In her prior conviction in April 2017, Villegas pleaded no contest to one misdemeanor count of providing false or misleading statements and was sentenced to two years of probation and 10 days of community labor. The 2017 conviction was the result of a previous Department of Insurance investigation, which discovered Villegas was transacting insurance without a license and misrepresented client information on insurance applications for a decade.

Consumers can check the license status of their agent or broker or contact the Department of Insurance at 800-927-4357 if they suspect they are victims of insurance fraud.

Both of Villegas’ cases were prosecuted by the Los Angeles County District Attorney’s Office.

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

T he 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/coursesWhat 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 on Insurance Videos

Zalma on Insurance

Over the last 53 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 and at https://rumble.com/c/c-262921 where I post a new video almost every day

Some videos available include:

The California Fair Claims Settlement Practices Regulations 2020

A Video Explaining Why Rescission Is a Remedy That Must be Used with Care

Some Cases Where Insurers or Insurance Agents or Brokers Were Convicted of Insurance Fraud

The California Fair Claims Settlement Practices Regulations 2020

A Video Explaining Why Rescission Is a Remedy That Must be Used with Care

Some Cases Where Insurers or Insurance Agents or Brokers Were Convicted of Insurance Fraud

A Video Explaining the Consideration for Early Settlement of a Construction Defect Suit

A Video Explaining the Statutes of Repose

A Video Explaining Some Grounds for the Tort of Bad Faith

 A Video Explaining How to Deal with Insurance Fraud and Innocent Co-Insureds

A Video Explaining an Insurer’s Dispute or Denial of a Claim

A Video Explaining Ethics and the Development of the Covenant of Good Faith

A Video Explaining Some Appellate Decisions on the Equitable Remedy of Rescission

A Video Proposal to Defeat Insurance Fraud Because It Takes Courage to Fight Insurance Fraud

A Video Explaining Insurance Fraud by "Staged" Losses

A Video Explaining the Preparation Necessary for a Statement or an Examination Under Oath

A Video Explaining The Role of the Insurer’s Attorney After Ending the EUO