Author Archives: Mark J. Rose, Esq.

Defendant’s Motion to Dismiss Granted with Prejudice in PIP Benefits Case Involving Challenge to “Emergency Medical Condition” (EMC) Provision

In a second ruling within one week involving Florida’s amended PIP law, the U.S. District Court for the Southern District of Florida dismissed a case challenging reimbursement under the amended statute’s “emergency medical condition” or “EMC” provision. See our earlier post titled Court Grants Defendant’s Motion to Dismiss in Robbins v. Garrison P & C.

Sendy Enivert sued her auto insurance company, Progressive Select, alleging breach of contract for failing to pay her PIP benefits to a limit of $10,000. Enivert’s claim involved the newly added provision to Florida’s PIP law which limits PIP benefits depending on whether a claimant has suffered an emergency medical condition.

Plaintiff Enivert interpreted this language to mean that an insured is limited to $2,500 only if a medical provider determines that there is no emergency medical condition. She argued that because, in her case, no medical provider ever made such a determination, she was entitled to the full $10,000. In other words, because no medical provider determined that she did not have an emergency medical condition, she was entitled to full benefits.

Defendant Progressive read the statute to mean the opposite, i.e., that a medical provider must affirmatively determine that an emergency medical condition does exist in order for the insured to be eligible for reimbursement of the full amount.

The court agreed with Progressive, concluding that the PIP statute clearly indicates that a determination that a claimant has suffered an emergency medical condition is required in order to receive benefits in excess of the $2,500 limit. Since a medical provider did not determine that Enivert had an emergency medical condition, she was not entitled to the full $10,000 in benefits.

The court also looked to the legislative intent behind the PIP statute. It concluded that the clear legislative intent was to decrease PIP fraud by placing more stringent requirements in order to receive the maximum amount of benefits.

Based on the above, the court granted Progressive’s motion to dismiss Enivert’s case.

The case is Sendy Enivert v. Progressive Select Insurance Co., Civil Action No. 14-CV-80279-Ryskamp/Hopkins (S.D. Fla. July 23, 2014). Click on the link to read the court ruling.

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

State Farm Granted Summary Judgment in Lake Worth Chiropractic PIP Benefits Case

On July 14, 2014, the 15th Judicial Circuit for Palm Beach County affirmed a lower court decision granting summary judgment to State Farm in a claim for PIP benefits brought by Lake Worth Emergency Chiropractic Center.

In the underlying case, Judge Bosso-Pardo granted defendant’s Motion for Final Summary Judgment, entering final judgment for the defendant, State Farm, upon finding that the pre-suit demand letter, required by Florida Statute 627.736(10) (2010), was insufficient in that it demanded payment for services that were never billed to State Farm.

Judge Bosso-Pardo found that the Plaintiff’s “withdrawing” the unbilled service after suit had commenced was insufficient to cure the defect and that the demand letter requirements under Florida Statute 627.736(10) must be strictly construed and adhered to by those seeking to initiate litigation against a Florida PIP insurer.

The Circuit Court affirmed this decision, concluding that section 627.736(10) requires strict compliance and that, in this case, the demand letter did not strictly comply with the PIP statute requirements. As such, Lake Worth Emergency Chiropractic Center failed to satisfy the condition precedent to filing its law suit, and the trial court was correct in awarding final summary judgment in favor of State Farm.

The case is Lake Worth Emergency Chiropractic Center v. State Farm, in the Fifteenth Judicial Court for Palm Beach County, Case No. 502012AP000034XXXXMB. Click on the link to read the court opinion.

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

Safe Driving Tips for the Fourth of July

As Florida residents make last minute plans to celebrate the Fourth of July holiday, drivers are encouraged to take a few minutes to conduct a quick safety check.

The Florida Department of Highway Safety and Motor Vehicles offers the following travel tips for those planning a road trip this weekend.

  • Plan a safe return trip before you leave for holiday activities.
  • Buckle Up. Seat belt use is the most effective way to save lives and reduce injuries.
  • If you plan to drink, appoint a designated driver.
  • If you find that you have had too much to drink, call a taxi or a sober friend or family member for a ride.
  • If you notice an impaired driver on the road, notify local law enforcement or dial *347.
  • If friends or family members who have had too much to drink plan to drive home, take their keys away and help them arrange safe travel.
  • Remember that possession of an open alcoholic beverage container in a vehicle (in motion or stopped) by the driver and or the passenger(s) is a violation of Florida law.

This is a public service message from Roig Lawyers. Have a safe and happy holiday.

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Filed under Uncategorized

“Family & Friends” Staged Accident Ring Uncovered in Duval County

A couple faces 20 years in prison as a result of their participation in a PIP insurance fraud scheme which involved staging a car accident, and subsequently collecting money from the false insurance claims they filed.

Jose Alberto Velez, 30, and April Rosita Wynn, 23, were both convicted of knowingly participating in an intentional motor vehicle crash and four counts of false insurance claims, according to a news release issued by the Office of the State Attorney for the Fourth Judicial Circuit of Florida.

Their convictions stem from a staged car crash that happened in May 2012, the same year that the State Attorney’s Office (SAO) and the Division of Insurance Fraud (DIF) began investigating a series of questionable car accidents in Duval County.

Their investigation uncovered a larger Personal Injury Protection (PIP) insurance fraud scheme where nearly 100 individuals have been arrested over the past 18 months.

It was discovered that Velez and Wynn, who are now married, persuaded family and friends to participate in their staged car crashes. After the accidents, Velez, Wynn and their accomplices would go to designated rehabilitation clinics that would provide mock therapy for fictional injuries, and then file PIP claims through those clinics.

One of the ringleaders of the scheme, David Rodriguez Lopez, was sentenced to 15 years on charges of schemes to defraud over $50,000, false insurance claims over $100,000, and knowingly participating in an intentional motor vehicle crash. Other cases resulting from the investigation are currently pending.

Besides their present charges, Velez and Wynn are still awaiting other charges for allegedly staging additional accidents. They will be sentenced the week of July 28.

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Filed under Insurance Fraud

Another Staged Accident Story Reminds Drivers to be Alert to Florida Auto Insurance Scams

Florida State Rep. Jim Boyd, R-Bradenton, helped pass legislation in 2012 aimed at reducing the tremendous number of staged accidents and injuries in the state, and deter claims made after accidents in which victims had not even been present.

Once estimated as a billion-dollar industry in Florida due to the ease of receiving PIP payouts from insurance companies, Boyd’s changes helped strengthen requirements for medical evidence and stipulated that police reports list everyone involved, including all of the passengers.

Credited with reducing personal injury insurance costs and premiums, Boyd feels that the updated law put a dent in a serious problem where opportunistic scam artists still turn dents and dings into major injuries.

One such example of heavy-duty suspicions stemming from a marginal accident was featured in a recent Tom Lyons’ column in the Herald-Tribune.

In Lyons’ piece, a Sarasota retiree was supposedly involved in an accident when backing out of an on-street parking spot. This driver felt the accident was so small that he wasn’t even sure it happened. However, the driver of the other car claimed that he caused the collision and filed a police report. The retiree was issued a ticket.

He later found out from his insurance company that the woman driving the other car filed an insurance report claiming she and her passenger suffered trauma and were feeling pain in their neck, legs and back. The retiree says, “his insurance company is about to take a hit, but he’s not at all sure it is a legitimate one.”

Some unscrupulous staged accident rings rely on each other to carry out these scenarios to receive insurance reimbursement, according to the article. Although some parties face charges in the end, it isn’t easy to know when someone is faking an injury. It is even harder, as demonstrated in the retiree’s case, to prove the circumstances surrounding the injury are bogus.

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

Three PIP Scammers Sentenced in Jacksonville Fraud Scheme

Three men, who staged car crashes and subsequently filed false Personal Injury Protection (PIP) claims through rehab clinics, were recently sentenced to multiple years in prison for their role in an insurance fraud scheme based in Jacksonville.

According to a news story on, the defendants were described as “mid-level recruiters,” who were arrested as part of a larger scheme that investigators from the Division of Insurance Fraud and State Attorney’s Office first uncovered in 2012. More than 20 people were arrested as a result of this investigation.

The participants would fake accidents and then go to clinics that prosecutors say were owned by the organizers of this scheme. These clinics provided bogus treatment for non-existent injuries.

George Orlando Ortiz Jr., 33, was sentenced to 9½ years in prison. He pleaded guilty to four counts of committing a staged motor vehicle accident, false insurance claims and schemes to defraud.

Also getting sentences were Noylan Barreto, 21, who received a three-year prison term and 10 years probation on two counts of committing a staged motor vehicle accident and one count of false insurance claims, and Freddie Alberto Freytes, 43, who received six years in prison on two counts of committing a staged motor vehicle accident and three counts of false insurance claims.

Insurance companies ran up a tab of more than $150,000 in claims resulting from accidents involving Ortiz, Barreto and Freytes.

Ringleader David Rodriguez Lopez, who we wrote about in our FL-PIP blog on December 11, 2013, was convicted and sentenced to 15 years in prison on charges of: schemes to defraud over $50,000, filing false insurance claims totaling over $100,000, and helping stage a deliberate automobile accident.

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Filed under Insurance Fraud

Miami-Dade Clinic Owner Arrested for PIP Fraud in ‘Operation No-Med Services’

Aurora Hernandez, who owned and operated Magic Hands Medical Services, has been arrested on PIP fraud charges for allegedly organizing and billing a staged accident.

According to an announcement by Florida Chief Financial Officer Jeff Atwater, her arrest is the latest in an aggressive crackdown called “Operation No-Med Services.” This investigation, which began in May 2013 and involves four accident clinics in Miami-Dade County, has led to the arrests of a medical doctor, two clinic owners, five medical licensees, six staged accident organizers and six other co-conspirators.

The Division of Insurance Fraud (DIF) said that its investigation revealed participants from five staged accidents were referred to clinics, including Magic Hands, for treatment that was not provided but still billed to insurance companies in excess of $408,000.

“I am proud of our investigators for their commitment to keeping fraudsters off the streets and out of the pockets of hard-working Floridians,” said CFO Atwater. “Every act of fraud drives up the cost of insurance and we refuse to allow those selfish acts to continue.”

For her role in the scheme, the 32-year old Hernandez faces a maximum of 235 years in prison.

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Filed under Insurance Fraud

Bill to Allow 75 MPH Speed Limit will be Vetoed, Florida Gov. Scott Says

On our April 4 blog post on the FL-PIP guide, “Florida Speed Limits May Rise to 75 MPH,” we discussed the contentious debate surrounding Senate Bill 392, a bill that proposed to raise the speed limit on Florida highways from 70 mph to 75 mph.

The latest development, according to an article in the May 15 Insurance Journal, is that the Governor plans to veto the bill amidst growing concern for the safety of state highway patrol troopers, among others.

Narrowly passing in the Florida Legislature last month, the bill would have allowed the Department of Transportation to increase speed limits on roads that are part of the National System of Interstate and Defense Highways and have at least four lanes. The department could have also raised the speed limit from 65 to 70 mph on rural, four-lane divided highways and up to 65 mph on other roads. Speed limits would have been increased at the department’s discretion, not automatically.

Scott said that he decided to “stand with law enforcement,” in light of the death of Master Trooper Chelsea Richard. She and two others were struck by a vehicle on May 3 while standing on the side of Interstate 75 near a traffic accident.

Sen. Jeff Clemens, D-Lake Worth, and one of the sponsors of the bill, pointed out that having speed limits raised in Florida in the past has not resulted in more fatalities, and said misgivings about safety and motorists driving even faster were inaccurate, according to the article.

The Florida branch of AAA and the president of the Florida Sheriffs Association are in favor of the veto and commended the Governor for his choice.

Since 1996, the maximum speed limit on Florida highways has been 70 mph.

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Filed under Fla. Stat. 627.736 (2008)

Orlando “Runners” Charged in a New Jersey Insurance Fraud Ring

Two brothers who allegedly acted as ringleaders and 10 other individuals from New Jersey and Florida face a multitude of charges for participating in a complex insurance fraud scheme that involved “runners” who recruited victims of car accidents as patients for medical and chiropractic services in order to make fraudulent claims.

According to a news story in the Asbury Park Press, two of the defendants—Cesar Huaman, 45, and Albert Hughes, 32—are from Orlando. They apparently facilitated the scam by channeling business to several chiropractic clinics throughout New Jersey and helped generate millions of dollars in overstated medical and legal bills in their role as runners.

Acting Attorney General of New Jersey John J. Hoffman was quoted in the article saying, “The runners allegedly picked up motor-vehicle accident reports at local police stations and then visited the home of accident victims in a personal and aggressive attempt to persuade them to utilize the chiropractic facilities owned, controlled and managed by the two ringleaders.”

“In many instances, the runners allegedly retrieved the motor-vehicle accident patients from their homes and personally drove them to the chiropractic facilities for the initial treatment that they would receive,” he added.

The New Jersey brothers, Anhaur Bandy, 50, and Karim Bandy, 53, allegedly reaped their millions in illegal insurance payments over a five-year time period. Although they are not chiropractors (a prerequisite under New Jersey law in order to own chiropractic facilities), they put straw owners in place to maintain their control.

The prosecutor of New Jersey’s Office of Insurance Fraud obtained a 45-count indictment against the 12, ranging from racketeering, conspiracy, criminal use of runners, and other related charges.

Among those involved in the scheme were a personal injury lawyer, a paralegal, a doctor and two chiropractors. The indictments were unsealed on May 8.

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Filed under Insurance Fraud

Florida Chiropractor Pleads Guilty in $3 Million Medicare Fraud Scheme

Chiropractor Michael Kelly Miller recently pleaded guilty in a Kansas City, Mo. federal court on one count of health care fraud after waiving his right to a grand jury.

Miller, 59, is the former owner of Waldo Rehabilitation Health & Wellness center in Kansas City, Mo. He now operates the Miller Clinic for Optimal Health in Temple Terrace, Fla., located outside of Tampa in northeastern Hillsborough County.

The Waldo clinic charged Medicare more than $3 million for nerve block injections between 2009 and 2011, according to the U.S. Attorney’s Office for the Western District of Missouri, and received $879,582 in reimbursements. Miller acknowledged in court that the treatments were false or fraudulent, because they were not medically necessary.

According to his firm’s current website, Dr. Miller is a chiropractor, acupuncturist, and naturopathic physician. He is also a Fellow of the Brazil American Academy for Aging and Regenerative Medicine.

Miller faces a jail term of 15 to 21 months in federal prison, and is ordered to repay Medicare restitution of approximately $880,000. A sentencing hearing is scheduled for a future date.

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Filed under Insurance Fraud