Tag Archives: PIP fraud

Adjusters Unsure about Questionable Claims Delve into Accident Data

In an earlier FL-PIP Blog post titled “Accident Reconstructionists assist Insurance Adjusters in Uncovering Staged Accidents,” we reported how insurance companies may hire accident reconstructionists to analyze car crash data from police reports, photographs, incident descriptions, and repair records to help determine whether car accident claims are real or if crashes were staged.

A recent article in Property Casualty 360° took a look at common scenarios where accident reconstructionists provide input to insurance adjusters. A summary appears below.

Car Accident Scenario #1

The driver of a vehicle said another car hit him from behind when he was slowing for traffic. The other car did not stop to exchange information.

The claims adjuster, who photographed the damage, was suspicious because he thought the damage looked old, the vehicle had recently been added to the policy, and the claimant received a check a few months earlier on a different vehicle but with a similar story.

The data that the accident reconstructionist researched for the different model years and their variants found that the top of the bumper of these vehicles was always at or below 22 inches. It was also determined that the damage showed no signs of paint transfer. Using this information, the accident reconstructionist was able to definitively conclude that the damage seen on the vehicle did not match the driver’s testimony. The claims adjuster denied the claim in full.

Car Accident Scenario #2

Minor contact between the rear of a Chevrolet Malibu and the front of a Hyundai Elantra was reported with the scuff on the Elantra noted to be consistent with a sliding motion. Further investigation was called in uncovering that the Malibu was in a previous crash severe enough to be sold with a salvage title. No other details, including repair records, were available. The driver of the Malibu claimed that in addition to a small dented area on the right rear corner of the rear bumper cover, there was damage to the Malibu’s trunk area, more prominent on the left side of the vehicle.

The accident reconstructionist had test data run on an Elantra from the same model from a 3-mile-per-hour corner impact test and was able to determine that the damage for the Elantra involved in the incident is consistent with a collision at less than 4.2-miles-per-hour. A Conservation of Momentum analysis was then performed and found that an impact resulting in a Delta-V (the change in velocity of the vehicle from its pre-impact, initial velocity, to its post-impact velocity) of 4.2 miles per hour for the Hyundai Elantra would result in a Delta-V of 3.5 miles per hour for the Chevrolet Malibu.

Test data was obtained from the Insurance Institute for Highway Safety (IIHS) for the Chevrolet Malibu and it was determined that the claim was for more severe damage than was sustained and that the damage was partially in an area that was too far away from the actual point of contact.

It was found that not all of the claimed damages to the Malibu could be attributed to contact from the Elantra, and the insurance company subsequently denied all costs associated with the underlying damages.

Every case is unique, and claims with injuries will be treated differently.

Click on the link to read the full article, “Is that auto accident staged? Here’s how to tell.”

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

Accident Reconstructionists assist Insurance Adjusters in Uncovering Staged Accidents

In some cases, auto accident claims raise red flags with insurers. The damage reported may be clearly visible and no claim for injury has been made, but adjusters just can’t put their finger on it. Before insurers pay the claim, however, they can bring in an accident reconstructionist to help put the pieces of the puzzle together and hedge against fraud.

According to an article in Property Casualty 360°, accident reconstructionists are investigators familiar with questionable claims such as when the vehicle damage doesn’t match the claimant’s story. Frequently, they do their work based on the claimant’s incident description, police report, repair records, and photographs.

Accident reconstructionists delve into many different aspects of the accident including: comparing the damages to the claimant’s statement of the sequence of events; making sure damages match the police report; and verifying that the damages between the vehicles meet the shape and height of the vehicles involved.

Key to making a conclusion lies in geometry and patterns of the vehicles and the damage they sustained. Photographs of the vehicle, in addition to information about the specific make and model enable accident reconstructionists to obtain the vehicle’s specific damage dimensions for use in their analyses. Even so, every case is different and must be considered independently before reaching a conclusion.

Because the scope of assignments are very specific, accident reconstructionists often can quote a price for their work based on the nature of the claim, available evidence, and whether a verbal update or a written report is required.

Input from accident reconstructionists may be invaluable to insurers. They sift through information and provide the missing data necessary to determine whether an accident was staged or if a claim is fraudulent.

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Filed under Insurance Fraud

Jeff Atwater, Facing Re-Election, Notes Success in Shutting PIP Clinics

Jeff Atwater has served as Florida’s Chief Financial Officer since January 4, 2011, and is up for re-election in November. He recently spoke with the editorial board at The News-Press in Naples about his accomplishments and priorities.

In a wide-ranging interview, Mr. Atwater emphasized Florida’s fight against fraud as an area of success. Some highlights from the interview follow.

“We have worked with sheriffs, the state attorney’s office, the FBI and locally with law enforcement, under the umbrella of financial literacy,” notes Mr. Atwater. “We are beginning to neutralize this. We are shutting PIP clinics and under-the-table transactions.”

Key accomplishments in the state’s continuing battle against fraud over the past three years include:

  • 5,000 insurance fraud arrests
  • 2,000 arrests in PIP fraud cases
  • $129 million in public assistance fraud uncovered

Atwater may run for governor or the U.S. Senate in four years, according to the article. He has served in public office since 1993, when he was elected Vice Mayor of North Palm Beach. He was elected to the House of Representatives in 2000 and the Florida Senate in 2002. In 2008 he was selected to serve as Senate President.

Click on the link to read the full article.

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Filed under Insurance Fraud

Florida’s Third-Party Bad-Faith Laws are Costly to State’s Auto Insurance, Says IRC Study

More than $800 million in additional auto liability claim payments were made in 2013 as a result of Florida’s third party bad-faith lawsuit environment.

Those findings were revealed in a recent study—“Third-Party Bad-Faith in Florida’s Automobile Insurance System”—conducted by the Insurance Research Council (IRC). This translates to an average of $79 in additional claim costs for every insured vehicle in the state.

From 1995 through 2013, Florida experienced a striking increase in the frequency of bodily injury liability claims and a significant jump of 68 percent in average claim payments per insured vehicle, according to the report.

Compare that to other large no-fault states that do not authorize third-party bad-faith lawsuits against insurers, such as New Jersey, New York and Pennsylvania, where notable declines in liability claim frequency and much smaller increases or even declines in claim payments per insured vehicle were found.

A contributing factor in Florida’s growing problem with third-party bad-faith lawsuits is believed to be the “apparent failure of the no-fault system’s tort threshold to limit access to liability reimbursement under most auto insurance policies,” according to the study. Other no-fault states’ systems are designed to limit the number of liability claims that are filed for reimbursement for lost wages and medical costs.

In contrast, Florida’s tort threshold appears not to minimize liability claim frequency. In 2013, Florida’s bodily injury claim frequency rate was not only higher than most tort system states (states without no-fault coverage), but was higher than the U.S. frequency rate for liability claims.

“The virtually unrestricted ability to file a third-party bad-faith lawsuit against an insurance company poses a serious threat to Florida’s auto insurance system,” said Elizabeth A. Sprinkel, CPCU, senior vice president of the IRC. “The possibility of winning large bad-faith settlements and court judgments creates powerful incentives for potential claimants and their attorneys to file auto liability insurance claims that otherwise would not be filed.”

The IRC said that it will be doing more research related to the impact of Florida’s tort threshold and other important aspects of the no-fault system and will publish those findings later this year.

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Filed under Insurance Fraud

Three Jacksonville Residents Charged with PIP fraud

Florida Chief Financial Officer Jeff Atwater recently announced that three Jacksonville residents have been arrested for personal injury protection fraud. The suspects—Yolanda Vargas, Christian Vargas, and Willdelyn Rodgriguez—have each been charged with one count of committing a staged motor vehicle accident and one count of insurance fraud.

A fourth suspect by the name of Felix Vargas, who has not yet been located, is alleged to have recruited the three individuals to participate in the fraud scheme. He is believed to be connected to a New York identity theft ring, as well as to an IRS scam in which he directed payment of others’ tax refunds to himself.

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Filed under Insurance Fraud

Chiropractor & Receptionist Connected to Operation Sledgehammer Get Prison Sentences

Convicted for their role in a massive insurance fraud ring involving staged accidents in South Florida, two more people were sentenced in Operation Sledgehammer last week.

Chiropractor Lawrence Schechtman from Parkland, whom we reported about on our FL-PIP Guide on December 19 when he pleaded guilty to mail fraud conspiracy and mail fraud, was sentenced to four years and four months in federal prison. In addition to his sentence, he was ordered by U.S. District Judge Kenneth Marra to pay more than $2.4 million in restitution.

According to federal prosecutors, Schechtman worked at clinics in Palm Springs and Miami, where he signed off on treatments for people who fraudulently claimed they were accident victims as part of the staged-accident ring which operated in several counties.

According to a story in the August 8 Sun-Sentinel, the 45-year old Schechtman, who suffers from heart and back problems, was granted a request to serve his confinement at the Federal Medical Center, a medical prison in North Carolina. Judge Marra gave the chiropractor two months to turn himself in and begin serving his term.

Another co-conspirator from Palm Springs was sentenced for her role in Operation Sledgehammer. Sircy Sacerio, also known as Sisi or Sircy Santos, received four years in federal prison by Judge Marra.

Under the terms of her sentence, the Palm Beach Post reported, the 31-year old reception and office assistant must also repay $1,146,824.26 and will have two years of supervised release following her time in prison.

She originally pleaded guilty to one count of conspiracy to commit mail fraud and five counts of mail fraud.

Part of the fraud activity in Operation Sledgehammer, which was recorded by investigators, included co-conspirators damaging vehicles with sledgehammers to give the appearance of a crash. The participants in the staged accidents would then go to clinics involved in the ring to receive bogus treatment which, according to the U.S. Attorney’s Office, brought in millions of dollar to chiropractors on false and fraudulent insurance claims. The scheme began around October 2006 and continued through December 2012.

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

Disbarred Florida Attorney Gets Prison Sentence in $28.3 Million Medicare Fraud

A disbarred Florida attorney who participated in a $28.3 million Medicare fraud scheme involving false claims for physical and occupational therapy services was recently sentenced in federal court in Tampa to 70 months in prison, the Justice Department announced.

Margarita Grishkoff, formerly of southwest Florida, initially pleaded guilty on January 24 to conspiracy to commit health care fraud. In addition to her prison term, U.S. District Judge Susan C. Bucklew of the Middle District of Florida sentenced the 60-year old to three years of supervised release and ordered her to pay $14,424,856 in restitution, jointly and severally with her co-conspirators.

Grishkoff, who is currently a resident of Charlotte, North Carolina, acknowledged in her guilty plea that approximately $28.3 million in fraudulent claims were submitted to Medicare by her and the scheme’s co-conspirators. Medicare paid approximately $14.4 million of those claims, which were made through physical therapy clinics throughout Florida from 2005 through 2009.

Court documents reveal that Grishkoff, who was disbarred in Florida in 1997, was vice president and director for Ulysses Acquisitions Inc., a Delaware holding company that purchased several comprehensive outpatient rehabilitation clinics and physical therapy providers to gain control of Medicare provider numbers. These clinics included: West Coast Rehab Inc. in Fort Myers; Rehab Dynamics Inc. in Venice; Polk Rehabilitation Inc. in Lake Wales; and Renew Therapy Center of Port St. Lucie LLC in Port St. Lucie.

The Justice Department also said that Grishkoff and her co-conspirators paid kickbacks to patient recruiters and clinic owners to get identifying information of Medicare beneficiaries and physicians. They subsequently took this information to create and submit false claims to Medicare through the clinics Ulysses Acquisitions owned. Claims for reimbursement were made on therapy services that were not legitimately prescribed or actually provided.

But it didn’t end there. Grishkoff and her co-conspirators used the clinics they controlled to submit false reimbursement claims on behalf of other clinics not owned by Ulysses, in exchange for a percentage of the Medicare reimbursement received.

These Miami-based therapy clinics included: Hallandale Rehabilitation Inc., Tropical Physical Therapy Corporation, American Wellness Centers Inc., and West Regional Center Inc. According to court documents, Grishkoff and her co-conspirators kept approximately 20 percent of the fraud proceeds and paid the remaining 80 percent to the co-conspirator clinic owners. Grishkoff further admitted that she arranged sham sales of her clinics to nominee or straw owners to disassociate herself and Ulysses Acquisitions from the fraudulent scheme. Those new owners were recent immigrants with no background or experience in the health care industry.

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Filed under Insurance Fraud