Insurance Agent Allegedly Sold Fraudulent Insurance Policy

According to the Palm Beach Post, Fred Thomas Jr., 39, is facing charges of fraud and embezzlement between $300 and $2,000 after he allegedly sold a Palm Beach County woman fraudulent/fake car insurance during a three-year period. Thomas was arrested by the Florida Highway Patrol on Interstate 95 for driving with a suspended license when the trooper found an active warrant for Thomas in the insurance fraud case.

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Filed under auto insurance, Auto Insurance Fraud, Florida, Insurance, Insurance Fraud, Palm Beach County

Pilot Theodore R. Wright III Faces Decades in Prison for Insurance Fraud

As reported by Flying Magazine, rising social media star Theodore Robert Wright III who gained notoriety for chronicling his larger-than-life flying exploits in photos on Facebook and Instagram has been charged with intentionally crashing his plane into the Gulf of Mexico to collect insurance money. Wright is facing serious prison time after federal law enforcement officials charged the 32-year-old with multiple counts of insurance fraud.

Wright and three associates (Shane Gordon of Texas, Raymond Fosdick of South Carolina, and Edward Delima of Hawaii) are charged with being involved in the destruction of a 1971 Cessna Citation, a Lamborghini Gallardo and a luxury sailboat in Hawaii, all to collect insurance payouts.

That’s not where the alleged fraud ended, prosecutors say. In an indictment filed in U.S. District Court in Tyler, Texas, Wright and three associates are charged with multiple felonies. Besides the Baron, officials say Wright was involved in the destruction of a 1971 Cessna Citation, a Lamborghini Gallardo and a luxury sailboat in Hawaii, all to collect insurance payouts. Prosecutors allege the men would acquire vehicles, insure them, destroy the vehicles and then collect the insurance money, a conspiracy that lasted from March 2012 to March 2017, according to the indictment.

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Filed under Insurance, Insurance Claims, Insurance Fraud

Auto Insurance Market to Shrink by 2050 According to KPMG

According to updated research by KPMG, the auto insurance market will shrink by more than 70 percent by 2050 due to autonomous vehicle technology and a rise in on-demand transportation, shifting liability to manufacturers.

KPMG did an updated study called The Chaotic Middle: The Autonomous Vehicle and Disruption in Automobile Insurance that shows an increase in the demand for new types of insurance products with traditional auto insurance carriers facing the threat of obsolescence. Auto manufacturers have become the likely alternative to covering driving risk according to the study.

According to the consulting firm, three major forces are disrupting the current auto insurance marketplace:

  • Autonomous Technology – making cars increasingly safer
  • Auto Manufacturers (OEMs) – assuming more of the driving risk and associated liability
  • Mobility-On-Demand – quickly translating into the need for less personal auto coverage

KPMG believes that all of this means that auto insurance carriers need to act now. “Insurance companies will have to make important strategic and tactical changes sooner than anticipated to navigate through this turbulent transformation of the industry,” said Jerry Albright, principal in KPMG’s Actuarial and Insurance Risk practice.

Click here to read the full article.

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Filed under auto insurance, Autonomous Technology, Insurance

Florida Insurance Rates Rise Thanks to Windshield-Replacement Schemes

According to Insurance Business America, your auto insurance premiums are going up, all because of ongoing windshield-replacement schemes.  As reported by Ryan Smith of Insurance Business America, these windshield schemes involve drivers with cracked windshields signing over insurance benefits to windshield repair and replacement shops.  These shops, through an “assignment of benefits”, will then submit an inflated invoice for the work allegedly rendered.

The Tampa Bay area has become the hub of the fraud and abuse involving these schemes.  More often then not, the fraudulent schemes are no fault of the insureds.   Florida law states that a deductible cannot be applied to windshield replacement and repair services.  This allows these shops to advertise that the work being done is “free” to the insureds.  The result of these “free” services has led to over 1900 windshield-claim lawsuits in Florida in 2016 alone; increasing litigation costs and ultimately hitting everyone’s pocket.

Click here for full article.

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Filed under auto insurance, Auto Insurance Fraud, Florida, Florida Division of Insurance Fraud, Insurance, Insurance Defense, Insurance Fraud, Windshield, Windshield Damage Scam

ROIG Attorneys Publish Ridesharing Article in Daily Business Review

ROIG Lawyers Attorneys Cecile S. Mendizabal and Lissette M. Alvarez published the article, “Ridesharing Legislation May Trigger New Wave of Litigation” in the Daily Business Review.

ROIG Lawyers Summer Law Clerk Yasbel Perez also contributed to the article.

Subscription required for full article.

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Filed under auto insurance, Claims Handling, FL Legislation, Florida, Insurance, Insurance Claims, Insurance Defense, Personal Injury Protection, PIP, PIP/No Fault, Ridesharing, Transportation Network Companies

Florida Doctors With Multiple Malpractice Settlements Face Little Discipline

According to Health News Florida, there are 29 Florida doctors operating with clear medical licenses although they have at least six malpractice complaints against them that have resulted in insurance payments since 2000. These doctors are continuing to practice without discipline from the state system that oversees them, which means either insurers paid to settle the cases that had no merit or the state hasn’t always followed up.

Critics say Florida’s system is broken and it’s putting people’s lives at risk. Dr. Sidney Wolfe, founder of the Public Citizen Health Research Group, based in Washington D.C has studied medical discipline nationwide for decades and says Florida’s Board of Medicine must intervene.

Patients and their families can also file a complaint with the state’s regulatory agencies, although the odds are stacked against them. 6,713 complaints and reports were filed with the Department of Health from 2015-2016. Only about 15 percent or 1,018 of them were found “legally sufficient.” Of those, 762 were taken to a probable cause panel, and three-fourths were rejected. The 188 administrative complaints filed that year represent less than 3 percent of the number of complaints and reports that came in.

In some cases involving doctors with multiple claims, records show the Department of Health received early warnings, but took little or no action. One of those cases was that of Dr. Michael Rosin, a Sarasota dermatologist who was convicted in March 2006 of defrauding Medicare of more than $3 million in a scheme that dated back more than a decade. He was sentenced to 22 years in prison and ordered to pay millions of dollars in restitution. After his criminal conviction, the Department of Health revoked his license, according to state records. Federal records show that Rosin, now 66, is at Otisville Federal Correctional Institution in Otisville, N.Y. He is scheduled for release in 2025.

Click here to read the full article.

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Filed under Department of Health, DOH, Florida, Florida Healthcare, Health care, Insurance, Malpractice

Discount Plan Organization (DPO): What is it and why should we know?

A “Discount Medical Plan Organization” was created in 2004 and is now simply called a “Discount Plan Organization (DPO).”

What is it and why should we know?

It is like a concierge medical agreement where a patient pays a fee, for example, $1,500/year to get quick access to a specific doctor.  Usually, the DPO is the only way to access specific practitioners.  It does little more than grant access, some prophylactic treatment, and the practitioners are usually the patients’ primary care physician.  You may see these organizations providing post-accident services.

Let’s make sure we are not also paying for the DPO in disguise through administrative CPT’s. Click here for the Bill Analysis.

Summary:

Discount Medical Plan Organizations (DMPOs) offer discount medical plans, in exchange for fees, dues, charges, or other consideration, which provide access for plan members to providers of medical services and the right to receive medical services from those providers at a discount. The Legislature established the regulatory scheme for DMPOs in 2004, which includes licensure, forms and rate filings and approval, disclosure requirements, and penalties.

CS/HB 577 renames a “Discount Medical Plan” and a “Discount Medical Plan Organization” as a “Discount Plan” and a “Discount Plan Organization” (DPO), and makes extensive conforming changes to part II of ch. 636, F.S., to reflect the new names. The bill clarifies the definition of a “Discount Plan” to exclude any plan that does not charge a fee to members. The bill removes all rate and form filing and approval requirements for DPOs. To increase flexibility in marketing and reduce administrative barriers for DPOs, the bill:

  • Defines “first page”, upon which certain disclosures must appear, to mean the first page of any marketing material that first includes information describing benefits;
  • Allows DPOs to delegate functions to marketers and binds DPOs to the actions of those marketers within the scope of the delegation; and
  • Allows marketers and DPOs to commingle certain information on forms, advertisements, marketing materials, or brochures.

To maintain consumer protections for members and potential members of Discount Plans, the bill:

  • Changes the disclosure requirements by requiring acknowledgement and acceptance of the disclosures before enrollment and creating visibility and follow up requirements for disclosures made by electronic means or telephone;
  • Establishes new cancellation and reimbursement requirements for DPOs to disallow any charges beyond the effective cancellation date;
  • Requires pro rata reimbursement of charges paid by a member for the months beyond the effective cancellation date; and
  • Requires pro rata reimbursement for members who cancel during an open enrollment period, upon return of his or her discount card.

The bill does not have a fiscal impact on state or local government.

The bill became law on June 14, 2017, and is now Chapter 2017-112, Laws of Florida.

If you have any questions or would like to discuss this issue in greater detail, please feel free to contact Dennis LaRosa (dlarosa@roiglawyers.com/850-264-6389) or any ROIG Lawyers attorney of your choice.

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Filed under FL Legislation, Florida, Insurance, Insurance Defense

New Opinion Released Regarding Examinations Under Oath (EUOs)

A new opinion was recently released by the Florida 9th Circuit Court in its appellate capacity interpreting Fla. Stat. § 627.736(6)(g) and the timely scheduling of Examinations Under Oath (EUOs). This case reaffirms that as a general rule, an insurer ought to schedule the initial EUO in any claim under investigation to occur within 30 days of receipt of the first bill to ensure that the investigation is being conducted well within the time limits set forth in the PIP statute without obliging the insurer to issue a payment of the subject bill prior to investigation.

In Geico Indemnity Co. v. Central Florida Chiropractic Care a/a/o David Cherry (2016-CV-000038-A-O), Central Florida Chiropractic sued Geico for breach of contract for failure to pay overdue PIP benefits. Geico asserted as an affirmative defense that coverage was appropriately denied because the assignor failed to appear for two EUOs.

Central Florida Chiropractic contested Geico’s above-described defense because the EUOs were scheduled to occur more than 30 days after the date on which Central Florida Chiropractic had submitted the bills for the alleged charges at issue and, thus, the EUOs were unreasonably set to occur beyond the 30-day statutory period for payment of said bills. In fact, the Court noted, the first EUO request was not even sent until after 30 days had lapsed. Further, Geico had not informed the claimant pursuant to Fla. Stat. § 627.736(4)(i) that his claim was pending investigation.

The 9th Circuit ruled that even though attendance at an EUO is a condition precedent to receiving PIP benefits under Fla. Stat. § 627.736(6)(g), this provision “cannot be read in a vacuum.” The Court specifically looked to section (4)(b), which requires provider bills to be processed within 30 days of receipt, and to section (4)(i), which states that the claimant should be notified in writing within 30 days of filing the claim that an investigation is under way. Geico argued that section (4)(i) permits a 60-day extension of time for investigation beyond 30 days, but the Court pointed out that Geico failed to send any letter notifying the claimant of the investigation in this case, so the 30-day window was not extended.

The Court also explained that timely payment of the provider bills does not foreclose the insurer from investigating the claim. Nonetheless, “nothing in the statute additionally excuses the insurer’s potential breach for failure to pay a PIP claim within 30 days as contemplated by section 627.736(4)(b).”

Therefore, Geico could not enforce the EUO as condition precedent to receiving PIP benefits because by the time it had scheduled the EUOs, it was already in breach of the policy as the provider’s bills were not timely paid within 30 days. “[B]ecause Geico was already in breach of the insurance contract before the EUOs were scheduled to take place, [the assignor] was not obliged to submit to them.”

The Geico case is the latest in a long line of opinions and trial court orders, starting with Amador v. United Auto. Ins. Co., 748 So. 2d 307 (Fla. 3d DCA 1999), which holds that an EUO does not toll or extend the 30-day period within which an insurer must pay otherwise timely, compensable charges pursuant to Fla. Stat. § 627.736(4)(b). Courts have also ruled that the insurer does not comply with the 30-day requirement if it coordinates the EUO within 30 days, but the EUO is nonetheless scheduled to occur beyond the 30-day window. (See Micro-Diagnostics & South Florida Inst. of Medicina a/a/o Luz Solarte v. United Auto. Ins. Co., 12 Fla. L. Weekly Supp. 248a (Fla. 11th Cir. Ct. App. 2004). In general, an insurer cannot defend claims on the basis of a claimant’s failure to attend an EUO if said EUO is scheduled to occur outside the 30-day period after submission of the medical bills. (See Humanitary Health Care, Inc. a/a/o Juan Esquivel v. United Auto. Ins. Co., 12 Fla. L. Weekly Supp. 531b (Fla. 11th Cir. Ct. 2005).

However, a Miami-Dade appellate court did find that an insurer may still benefit from the claimant’s failure to appear for an EUO if said EUO is initially scheduled to occur within 30 days, but then rescheduled for a later date at the claimant’s request. (See West Dixie Rehab. & Medical Ctr. v. State Farm Fire & Casualty Co., 10 Fla. L. Weekly Supp. 16a (Fla. 11th Cir. Ct. App. 2002)).

The above cases make clear that any communications regarding the re-scheduling of an EUO ought to be done in writing, with language that clearly communicates that the change in date was done to accommodate the request of the insured or insured’s attorney. When appropriate, the insurer may send a letter to the claimant or claimant’s attorney pursuant to section (4)(i) advising that a claim is under investigation within 30 days of the claim filing. This will extend the time period within which an investigation may be conducted up to 90days after the submission of the claim, and thus allows additional time before any provider bills must be processed.

If you have any questions or would like to discuss this issue in greater detail, please feel free to contact us.

ROIG Lawyers is a minority-owned litigation firm with a primary focus on Insurance Defense Litigation. We serve as primary counsel for numerous national and regional carriers and corporations related to all aspects of insurance litigation from 7 offices throughout the state of Florida. ROIG Lawyers does not intend to create an attorney-client relationship by offering this information, and anyone’s review of the information shall not be deemed to create such a relationship. E-mail list/s from ROIG Lawyers are intended to provide information of general interest to the public and are not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific legal issues that require attention.

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Filed under auto insurance, Case Law, Claims Handling, Examinations Under Oath (EUO), FL Legislation, Insurance, Insurance Claims, Insurance Defense, Personal Injury Protection, PIP, PIP/No Fault

New Amendments Affecting Anti-Fraud Investigative Units

The Legislature has passed some amendments that are likely to affect your SIUs. We have reviewed the new law and would like to provide you with a summary of some of the most important points.

Chapter 2017-178, Laws of Florida, primarily amended § 626.9891, Florida Statutes and went into effect June 26, 2017, when the Governor signed the bill. These amendments deal with insurer “anti-fraud investigative units.” There is very little, if anything, that must be done now other than learn the law and know what your responsibilities and timelines are.

Although you have an SIU to cover the main features of the law, some new reporting requirements and designation of an anti-fraud unit with at least 2 hours of initial anti-fraud education and 1 hour per year after that, will require all insurers “to investigate and report possible fraudulent insurance acts” to Florida government. The amendments to § 626.9891 [insurer anti-fraud investigative units; penalties for noncompliance], Florida Statutes, provide the who, what, how, when and where.

SUMMARY

*There is no legislative staff analysis of this law

By December 18, 2018, DIFS shall create best practices for the detection, investigation, prevention, and reporting of insurance fraud and other fraudulent insurance acts. The report must be updated as necessary but at least every 2 years. The report must contain specified criteria set forth in the section.

The Department of Financial Services is authorized to create rules for the administration this section. This is neither the Office of Insurance Regulation nor the Financial Services Commission (Governor and selected cabinet).

While there are compliance dates for insurers and agencies, the bill became effective upon becoming a law on June 26, 2017. By December 31, 2017, each insurer must:

  • If not in-house, contract with others to provide anti-fraud services
  • Adopt anti-fraud plan (discussed below)
  • Designate at least one employee to provide these services
  • Electronically submit reports of anti-fraud plan with the name and contact information of designated person to DIFS
  • The additional cost to the insurer for compliance may be added as an administrative expense in rate requests

Each anti-fraud plan shall include:

  • Procedures for mandatory reporting of insurance fraud
  • Acknowledgement that the insurer provides education and training required by section
  • Description of anti-fraud education and training
  • Description or flow chart of anti-fraud unit
  • Rationale and justification for level of staffing and resources used by anti-fraud unit based upon specified criteria

By December 31, 2018, each insurer shall provide staff of the anti-fraud investigative unit at least 2 hours of initial anti-fraud training that is designed to assist in identifying and evaluating instances of suspected fraudulent insurance acts in underwriting or claims activities.

Annually, after the initial training, an insurer must provide such employees a 1-hour course that addresses detection, referral, investigation, and reporting of possible fraudulent insurance acts for the types of insurance lines written by the insurer.

The insurer shall report to DIFS specified information by December 19, 2019, and annually thereafter for each line carried:

  • Number of policies in effect
  • Amount of premiums written
  • Number of claims received
  • Number of claims referred to anti-fraud unit
  • Number of fraud related matters referred to anti-fraud unit that were not claim related
  • Number of cases referred to DIFS
  • Number of case referred to other LE agencies
  • Number of cases referred to other agencies
  • Estimated dollar exposure submitted to DIFS or other agencies

In addition to reporting for all lines, workers compensation lines shall also report by December 19, 2019, the following information:

*This is a decrease in the amount of information currently required for workers compensation fraud before the amendment

  • Estimated dollar amount lost due to workers comp fraud]
  • Estimated dollar amount recovered attributed to workers comp fraud for several designated criteria
  • Number of workers comp fraud cases referred to DIFS for several designated criteria

Creating § 626.9896 Dedicated insurance fraud prosecutors:

  • DFS shall collect specified data from each state attorney who has designated attorneys and paralegals exclusively for the prosecution of insurance fraud.  [criteria omitted]
  • DIFS shall report the data to the house and senate leaders by September 1, 2018, and annually after that.

Other provisions not discussed; viatical contracts; HMO anti-fraud unit requirements; stranger-originated insurance policies are now statutorily considered void and unenforceable; an insurer may opt out of preinsurance inspection of private motor vehicles.  Preinsurance inspection reports of DIFS are eliminated.

 

These are the highlights of the bill as it applies to automobile insurance.  It does affect other lines as mentioned and we would be happy to explain the law in greater detail should you request it. If you have any questions, suggestions or reservations, please do not hesitate to contact us so that we may assist you in not only understanding the new law but how it ought to be implemented and when.

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Filed under FL Legislation, Florida, Florida Division of Insurance Fraud, Insurance, Insurance Claims, Insurance Defense, Insurance Fraud

Casselberry Residents Being Targeted by Windshield Replacement Scammers

Casselberry, Florida residents are victims of windshield replacement scammers. As reported by News 6, a Casselberry resident recently told police that two men came to her door claiming to work for the state government, insisting that a new law had been enacted that requires Floridians to replace their windshields every six months. As a result, the residents become victims, often times being exposed to an increased risk of a cheap windshield popping out and breaking during an accident. In turn, the scammers will contact the victim’s auto insurer and submit an inflated invoice for a service that was not necessary or properly done; potentially resulting in an increase in the victim’s auto insurance premium.

An increased premium is not the only risk insureds face with these scams, according to the Coalition Against Insurance Fraud, insureds could face possible fines and, even worse, jail time. Making a repair claim for a windshield you know is undamaged could get you convicted of insurance fraud.

Red flags should go up if someone shows up at your door or chases you down in a parking lot offering to fix your windshield for free. If you believe your windshield has sustained damage and needs to be repaired or replaced, call your insurance company for a list of rebuttable windshield repair/replacement companies.

For more information regarding the windshield repair scams and what you can do to fight back, visit http://www.insurancefraud.org/scam-alerts-windshield.htm.

Click here to read full article.

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Filed under Florida, Insurance, Insurance Claims, Insurance Defense, Insurance Fraud, Uncategorized, Windshield, Windshield Damage Scam