538 episodes

Presentation of insurance issues relating to claims handling, insurance coverage, interpretation of insurance policy coverages, insurance fraud, and investigation. Support this podcast: https://anchor.fm/barry-zalma/support

Zalma on Insurance Barry Zalma

    • Business

Presentation of insurance issues relating to claims handling, insurance coverage, interpretation of insurance policy coverages, insurance fraud, and investigation. Support this podcast: https://anchor.fm/barry-zalma/support

    GEICO v. Fraudulent Health Care Providers

    GEICO v. Fraudulent Health Care Providers

    Man Bites Dog Story - GEICO Sues Health Care Providers for Fraud

    https://zalma.com/blog


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    • 13 min
    Insurer Proactive Against Fraud

    Insurer Proactive Against Fraud

    CIGNA Obtains $14,371,384.95 Judgment Against Fraudulent Health Care  Provider

    Since police, prosecutors and state insurance fraud investigators are  seldom willing to arrest or prosecute insurance fraud perpetrators it is  necessary for insurers to be proactive and sue those who attempt or  succeed in defrauding insurers.  In Connecticut General Life Insurance Company and CIGNA Health And Life  Insurance Company v. Mike Ogbebor and Stafford Renal LLC, No. 3:21-cv-00954  (JAM), United States District Court, D. Connecticut (September 6, 2022)  CIGNA successfully sued a fake provider and obtained a default judgment  for almost $15 million against the corporate defendant and its alter  ego individual. FACTS  Stafford Renal LLC (Stafford) and its owner Mike Ogbebor, received  insurance payments from the plaintiffs, Connecticut General Life  Insurance Company and Cigna Health and Life Insurance Company  (collectively, “Cigna”), for dialysis Stafford claims to have  administered to two Cigna plan members. Cigna alleged that Stafford was  not licensed to provide, and in fact, did not provide these dialysis  treatments.  After Cigna filed its complaint Ogbebor submitted an answer on behalf of  both defendants. The trial judge struck this answer with respect to  Stafford because Ogbebor as a non-lawyer could not represent in court a  limited liability company such as Stafford. Cigna then moved for a  default entry against Stafford, which was granted based on Stafford’s  failure to appear or respond.  As for Ogbebor, he has failed to object or respond in any way to Cigna’s  discovery requests. Ogbebor  also failed to respond to a motion to  compel discovery, despite the Court’s discovery order warning him that  such failure might result in sanctions including default judgment. Cigna  now moves for default judgment against both Stafford and Ogbebor.  DISCUSSION  When a defendant defaults, it thereby admits all well-pleaded factual  allegations contained in the complaint. The trial court found that  default judgment is the appropriate sanction in this case and that any  lesser sanction would be futile in light of Ogbebor’s willful and total  refusal to cooperate with this litigation since he was first served in  February 2022 with discovery requests concerning information in his  possession that is essential for the resolution of Cigna’s claims  against him. CONCLUSION  Judgment was entered against Mike Ogbebor and Stafford Renal LLC in the  joint and several amount of $14,371,384.95, as well as a declaratory  judgment that the plaintiffs are absolved of any liability to pay past  or future claims submitted by Stafford Renal LLC.


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    • 13 min
    Insurer Sues Fraudsters

    Insurer Sues Fraudsters

    Physicians Cheat Insurer for Covid Testing


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    • 10 min
    Prosecutors Allow Arson-for-Profit to Succeed

    Prosecutors Allow Arson-for-Profit to Succeed

    Stupid Plea Bargain Destroys Insurer’s Right to Restitution


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    • 11 min
    What is Actual Cash Value?

    What is Actual Cash Value?

    Insurers, working without legislative or judicial direction, created a  working definition of the term “actual cash value.” Insurers recognized that ACV in a fire insurance policy was designed to  establish a dollar value for items of destroyed property that were not  new at the time of loss. Since the insurers had no easy means to  establish the used value of property, they selected the following as  their working definition of “actual cash value”: “Actual cash value is  the cost to replace with like kind and quality less physical  depreciation.” [Jefferson Insurance Company of N.Y. v. Superior Court, 3  Cal. 3d 398 (1970).]  The working definition, although it did not always provide the complete  indemnity contemplated by the insureds and by the various legislatures,  was eminently practical.


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    • 11 min
    Vermont Did Not Find CoverageInsurance Claims Law

    Vermont Did Not Find CoverageInsurance Claims Law

    In Huntington Ingalls Industries, Inc. et al. v. Ace American Insurance  Company et al, No. 2021-173, 2022 VT 4 Supreme Court of Vermont  (September 23, 2022) the Supreme Court of Vermont reversed a decision  refusing to allow an insured ship builder to recover business  interruption losses as a result of government orders dealing with  Covid-19 and remanded the case to the trial court to determine if Covid  caused direct physical damage to property. 

    FACTS 

     Insured, Huntington Ingalls Industries, Inc., is the largest military  shipbuilding company in the United States and provides professional  services to government and industry partners. It employs over 42,000  people, the majority of whom work at its shipyards in Virginia and  Mississippi.  In March 2020, insured purchased a property insurance policy (Global  Policy) from insurer Huntington Ingalls Industries Risk Management LLC,  its captive insurance subsidiary and a Vermont corporation.   The insured kept its shipyards open but made changes to its operations  to comply with CDC guidance and protect employees.


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    • 15 min