Author Archives: Fernando L. Roig, Esq.

Court Grants Defendant’s Motion to Dismiss in Robbins v. Garrison P & C

On July 18, the U.S. District Court for the Southern District of Florida dismissed a case in which the plaintiff challenged reimbursement under the amended statute’s “emergency medical condition” (“EMC”) provision.

Glenaan Robbins sued her auto insurer, Garrison P&C Insurance Co., alleging that Garrison violated the 2013 provision of Florida’s PIP law that limits PIP benefits depending on a determination of whether or not the claimant suffered an emergency medical condition.

Robbins sustained injuries in an April 2013 car accident. She was treated for her injuries and alleged that ultimately “no determination was made that she did not have an emergency medical condition.” When Robbins submitted her claim to her insurer Garrison, Garrison limited her reimbursement to $2,500.

FL PIP law requires that an insurance company must reimburse its injured insured up to $10,000 if certain medical providers determine that the injured person had an emergency medical condition. Reimbursement is limited to $2,500 if a provider determines that the injured person did not have an emergency medical condition.

In this case, no determination was made either way that an emergency medical condition did or did not exist. Plaintiff Robbins argued that where there has been no such determination, insurance companies must reimburse medical expenses up to $10,000. In other words, unless a determination of no emergency medical condition is made, the plaintiff is entitled to the higher amount.

Reviewing the language of the statute and legislative intent, however, the court concluded that Robbins’ argument had no merit. Rather, where there has been no determination of an emergency medical condition made, PIP medical benefits are not to exceed $2,500. Thus, contrary to Robbins’ argument, the conclusion of the court was that unless there is a determination of an emergency condition, the reimbursement is limited to $2,500.

The court therefore held that Robbins had failed to allege a statutory claim and her case was dismissed.

The case is Glenaan Robbins v. Garrison Property & Casualty Insurance Co., Civil Action No. 13-81259-Civ-Scola (S.D. Fla. July 18, 2014). Click on the link to read the court ruling.

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Filed under Case Law, Fla. Stat. 627.736 (2012)

Vehicular Arson Cases Climbing Nationwide

The slow economy could be contributing to an increase in claims involving auto fires, according to an official with the Washington, D.C.-based Coalition Against Insurance Fraud.

“Common sense tells you that more desperate people will take more desperate measures to get themselves out of trouble,” said Coalition representative James Quiggle in a News 4 I-Team report.

Cracking the case on vehicular arson is difficult to prove in court, as Maryland officials are discovering. Of more than 2,000 suspected auto arsons in the state during 2013, fewer than 50 cases had sufficient evidence to turn the matter over to prosecutors.

Findings from a 2009 report of the U.S. Fire Administration’s (USFA’s) National Fire Incident Reporting System (NFIRS) reveal the following:

  • Approximately 10 percent of all vehicle fires are intentionally set.
  • Intentional vehicle fires are at their highest during the summer, with a July peak.
  • Matches are the leading heat source (20 percent) of intentionally set vehicle fires.
  • Vehicle seats (34 percent) and uncontained fuel (14 percent) represent the starting point of many intentionally set vehicle fires.

Arson generally has a low clearance rate, according to crime reports from the U.S. Department of Justice. Arson involving motor vehicles, which represent 20 percent of all arson cases, have a particularly low closure rate of approximately 7.4 percent nationwide.

The Florida Department of Law Enforcement statistics indicate that motor vehicle arson may not be a major concern in the state, with fewer than 300 cases of auto arson reported for 2012.

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Filed under Fla. Stat. 627.736 (2008), Insurance Fraud

Woman Arrested for Forging Doctors’ Signatures to File $80,000 in Fraudulent Medical Insurance Claims

A Florida woman, who recently moved to Georgia with her family, had racked up more than $80,000 in false medical insurance claims when she was arrested last week.

According to a news release by Florida Chief Financial Officer Jeff Atwater, Tawania Weekley faces 80 different criminal counts after illegally filing claims for emergency room care, hospital stays, medical equipment, and multiple medical tests including MRIs, EKGs and x-rays that were never performed.

Weekley’s insurance carriers tipped off the Department of Financial Services’ Division of Insurance Fraud (DIF).

A subsequent investigation uncovered a plan where Weekley doctored and created new medical claim forms with forged physicians’ signatures, and then submitted those documents for reimbursement under her accidental and cancer indemnity policies.

The DIF found that she filed a total of 20 claims under the accidental policy for herself and immediate family members, and one additional claim under the cancer policy for herself.

“Every fraudulent claim drives up the cost of insurance in Florida,” CFO Atwater said. “I’m grateful to our investigative team and partners for working tirelessly to protect the hard working and honest people of Florida from harmful acts of fraud.”

DIF investigators worked with the Grady County Sheriff’s Office in Cairo, Georgia, to make Weekley’s arrest. She remains in jail while awaiting extradition to Florida.

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Filed under Insurance Fraud

Three Arrests Made in Connection to a Fort Lauderdale Staged Auto Crash

Three people in Fort Lauderdale have been arrested for their involvement in staging an auto accident in a church parking lot in order to collect $80,000 from an insurance company, a June 19 article in the Sun Sentinel said.

According to police records, Claudio Boyett, 44, Leslie Martinez, 45, and Claudia Hoy, 31, all of Fort Lauderdale, are accused of grand theft and insurance fraud. Boyett was arrested earlier this week while the other two were arrested last week.

A report from Florida’s Division of Insurance Fraud showed a U-Haul truck struck a Dodge Caravan in the parking lot of the Pare De Sufrir Church on August 7, 2012. Martinez was driving the Caravan, which had Hoy and six others as passengers. Boyett struck the van with the U-Haul he was driving, the report said.

After the accident, Martinez, Hoy and Boyett allegedly went for medical treatment and filed a personal injury protection claim with United Auto Insurance worth $80,000, according to insurance company investigators.

Officials from the insurance company said investigators found that one witness was offered $1,500 for the use of her Caravan; another acknowledged the accident was staged.

These arrests have come as a result of Operation Sledgehammer, the effort between the FBI and state authorities which launched three years ago to crack down on insurance fraud from staged auto accidents.

According to the story, investigators have found almost $20 million in illegal payouts and have charged almost 100 people in Broward, Palm Beach and Miami-Dade counties. Also, $5 million in restitution has been ordered to be paid back to insurers by some of those convicted.

These types of efforts have been making an impact in Florida, according to a study by the nonprofit National Insurance Crime Bureau. The organization has found fraudulent claims from staged crashes have actually been falling since Florida’s PIP reform has been enacted in the past two years, as our FL-PIP Blog reported in March.

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Filed under Insurance Fraud

4th District Court of Appeal Denies Rehearing in PIP Benefit Dispute

The Fourth District Court of Appeal has denied motions for rehearing by appellants in a PIP case decided in the insurer’s favor. The case was the consolidation of two separate PIP cases.

Insureds in both cases sought treatment for injuries sustained in separate accidents and assigned their PIP benefits to their treatment providers. One of the insurers, State Farm, reduced the amount paid to Northwood Sports Medicine, and Northwoods subsequently sued. Prior to that filing, the insured’s PIP benefits were exhausted. State Farm moved for summary judgment; Northwoods amended its complaint to allege that State Farm reduced payments in bad faith. The trial court granted the motion for summary judgment on the sole ground of exhaustion of benefits.

Likewise, in the second case, the insured assigned his benefits to Wellness Associates of Florida. USAA Insurance Co. reduced the payments to Wellness, and Wellness filed a complaint for damages. At the time the suit was filed, less than $14 in unpaid PIP benefits remained and, while the lawsuit was pending, PIP benefits were exhausted. USAA moved for summary judgment, Wellness amended its complaint to allege bad faith, and the trial court entered summary judgment based upon exhaustion of benefits.

For jurisdictional reasons, the appellate court transferred the Northwoods case to the circuit court. The question that the appellate court answered in the affirmative in the Wellness case is whether post-suit exhaustion of benefits absolves the insurer from responsibility to pay an otherwise valid claim where the exhaustion occurred after the insurer: (1) paid an amount that the provider claims is less than required by the contract; (2) received a pre-suit demand letter notifying the insurer of the medical provider’s dispute; and (3) was served with the filed complaint.

In its rationale, the court extended its decision in Simon v. Progressive, rejecting the “reserve or hold” theory by which an insurer is to put money in reserve if it denies or reduces a claim until that claim is resolved. The court concluded that “where the reasonableness of the provider’s claim is in dispute, post-suit exhaustion of benefits extinguishes the provider’s right to further payments, as long as exhaustion is prior to the establishment of the amount to which the medical provider is entitled to under PIP.” The court concluded that post-suit exhaustion of benefits—as was the case in Wellness—should be treated no differently than pre-suit exhaustion of benefits, as long as the amount of PIP benefits to which the provider is entitled has not been established. The court therefore affirmed the final judgment of the trial court in Wellness.

The case in the District Court of Appeal of The State of Florida Fourth District, January Term 2014, is Northwoods Sports Medicine and Physical Rehabilitation, Inc., (A/A/O Suzanne Cabrera), and Wellness Associates of Florida, Inc., (A/A/O Daniel North), Appellants, v. State Farm Mutual Automobile Insurance Company and USAA Casualty Insurance Company, Appellees, Nos. 4d11-1556 and 4d11-3796, [March 5, 2014]. Click on the link to read the June 4, 2014 ruling in the case.

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Filed under Case Law, Fla. Stat. 627.736 (2008)

Hollywood Police Look for Insurance Fraud during Traffic Stops

Broward County drivers traveling through Hollywood may be part of routine traffic stops that police are conducting throughout Wednesday to make sure drivers have appropriate auto insurance.

According to an article in the May 28 Sun Sentinel, agents from more than 20 insurance companies are helping police officers spot fake documents.

The joint operation between the National Insurance Crime Bureau and Hollywood Police aims to check drivers and crackdown on insurance fraud, which occurs in about one in every four drivers in Florida, the Insurance Research Council (IRC) says.

Penalties will vary with the level of the offense. Motorists with expired insurance cards are likely to receive a citation. Arrests may be in store for drivers with fraudulently altered insurance documents, according to officials.

Florida is one of the leaders in insurance fraud. According to the IRC, almost 24 percent of all Florida drivers don’t carry auto insurance, putting it in the top five states.

Operations like this one will help to drive down insurance rates and ensure coverage for those involved in auto accidents, the article explained.

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Filed under Insurance Fraud

Burning Vehicle Demonstration is a Lesson in Auto Insurance Fraud

It was auto insurance fraud in action.

Using burning vehicles as their teaching tool, Infinity Auto Insurance teamed up with the Miami-Dade Fire Department to show insurance adjusters and firefighters how they can detect fraud.

According to a Local 10-WPLG Miami News Broadcast, the fires were started with flares and were contained in a controlled environment. The blazing cars showed how the fire behaved and spread.

“We’ve decided to burn a couple of vehicles to teach the investigators how to detect this fraud,” said Carlos Torres of Infinity Auto Insurance. “The fraud in Florida is very high. Usually people have a financial motive or don’t like their car anymore, so they’ll set them on fire to make them a total loss,” he explained in the news piece.

Of the five top cities in the nation in auto insurance fraud, four of them are in Florida: Miami, Hialeah, Orlando and Tampa.

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Filed under Insurance Fraud

Pensacola Chiropractor Sentenced in Insurance Fraud

More than six years in prison and 10 years probation was the sentence handed down to a Pensacola chiropractor who was discovered pressuring patients to overstate their injuries in order to receive large insurance settlements, according to a news release from the Florida Department of Financial Services.

Dr. Russell Dominick, 54, was found guilty of racketeering and grand theft after a clandestine operation exposed his deceptive scheme. An undercover officer posing as a patient was encouraged by Dominick to exaggerate injuries in order to inflate the payment received by insurance.

The Department of Financial Services’ Division of Insurance Fraud began to covertly look into the issue after it received a complaint about Dr. Dominick. Similar experiences were then reported by other patients who also received advice from Dr. Dominick to embellish their injuries.

“Insurance fraud places a financial strain on hard-working Floridians through increased insurance premiums,” said Florida Chief Financial Officer Jeff Atwater. “I am extremely proud of our investigators for working so diligently with our law enforcement partners to put an end to this illegal operation.”

Dominick was arrested by the Escambia County Sheriff’s Office. The Florida Department of Law Enforcement and the Department of Health assisted with the investigation. The State Attorney’s Office for the First Judicial Circuit prosecuted the case.

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Filed under Insurance Fraud

Wal-Mart Adds Car Insurance to its List of Services

Wal-Mart is branching out into auto insurance.

The nation’s largest retailer has teamed with AutoInsurance.com to offer a free price comparison service that lets its customers quickly find and choose car insurance policies online and in real time in order to lower their costs.

While Wal-Mart is not selling car insurance, shoppers can log on to AutoInsurance.com or access the site through Wal-Mart’s website at http://www.walmart.com/autoinsurance.

According to a story on Claims Journal, the site will retrieve customers’ current auto insurance policy information to those who log on and provide their name, address, date of birth and contact information. AutoInsurance.com can then automatically complete the required coverage information for a side-by-side comparison. Within minutes, the service provides multiple quotes from some leading insurance companies including Esurance, Safeco and Progressive, the article reported.

Customers can then opt to buy the policy online right away, speak with a licensed agent at 800-700-7500, or save their information and purchase a policy later.

The service is currently up and running in eight states: Arkansas, Louisiana, Mississippi, Missouri, Oklahoma, Pennsylvania, Tennessee and Texas, and will be rolled out nationwide in the next few months. Wal-Mart shoppers will see in-store displays promoting the service.

In a recent media briefing, Daniel Eckert, senior vice president of services for Wal-Mart U.S., said that the company will be AutoInsurance.com’s exclusive retail partner and collect promotion payments in its role as marketer. In turn, AutoInsurance earns a commission every time a policy is sold.

AutoInsurance.com is a division of Fort Lee, N.J.-based Tranzutary Insurance Solutions LLC, a licensed property and casualty insurance agency that was created after Wal-Mart saw an opportunity to improve this market. Wal-Mart noted that car insurance is among the biggest monthly expenses of its customers, sometimes even topping health care costs for some of them.

Joshua Kazam, founder of AutoInsurance.com and the founder and chairman of Tranzutary, surveyed people and found that 90 percent comparison price shop for online for products and services like airline tickets, but only one in five do so for auto insurance because the process is so complicated.

Together, they’ve created a quicker service where shoppers can buy and save on car insurance and where shoppers receive their final price—no bait and switch tactics.

Before deciding on its current program, Wal-Mart tried out several pilot programs with Tranzutary, including one frontrunner where customers in Pennsylvania, who purchased policies from AutoInsurance.com, saw annual savings of $1,168, on average, Claims Journal reported.

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Filed under Fla. Stat. 627.736 (2008)

Three Chiropractors Found Guilty of Federal Fraud Charges

Three Florida chiropractors involved in a plan to fraudulently obtain money from insurance agencies have been found guilty on federal money laundering and mail fraud charges.

The chiropractors—Hermann Diehl of Miami, Kenneth Karow of West Palm Beach, and Hal Mark Kreitman of Miami Beach—helped set up staged automobile accidents and then filed fake claims for “victims” of the crashes. They also billed insurance agencies for procedures that were not actually performed.

The verdict was rendered on April 22 by a jury in the U.S. District Court for the Southern District of Florida. A fourth defendant, Joel Antonio Simon Ramirez of West Palm Beach, was found guilty of helping to stage the accidents.

All four of the defendants were found guilty of money laundering and mail fraud, with sentencing set for July. They each face a maximum sentence of 20 years in prison.

Readers of FLPIPGuide.com may recall that we wrote about Dr. Karow in a May 17, 2013 post titled, “92 Accused in Staged Accident Fraud Ring, $20 million in Fraudulent Claims.” At that time, an Operation Sledgehammer investigation revealed that chiropractors Lazaro Rodriguez, then 58, of Doral, and Kenneth Karow, then 53, were recruited to serve as owners of clinics involved in the ring.

 

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Filed under Case Law, Insurance Fraud