Category Archives: Florida

Geico Sues Florida Health Clinic for ‘Unnecessary’ Massage Claims

As reported by Law360, Geico sued Medical Wellness Services Inc. of Miami, FL for allegedly making $1.2 million in claims for providing medically unnecessary treatments for automobile accident victims who were eligible for coverage under their no-fault insurance policies. According to Geico, some of the claims were for services that were not actually provided and contained billing codes that misrepresented and exaggerated the services.

“The defendants do not now have — and never had — any right to be compensated for the fraudulent services that were billed to Geico through Medical Wellness,” Geico said. Geico claims Medical Wellness Services Inc. submitted claims for massage therapist services which are not reimbursable because Florida law prohibits no-fault insurance reimbursement for massages or other similar services.

According to the suit, the scheme began no later than 2013 and continues to this day. In addition to the request for $1.2 million in damages, Geico is also requesting a declaration from the court saying it will not have to pay any pending fraudulent claims by the health clinic which totals more than $75,000.

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Filed under Auto Insurance Fraud, Florida, Insurance, Insurance Claims, Insurance Defense, Insurance Fraud, Miami-Dade County, Miami-Dade Fraud, Personal Injury Protection, PIP/No Fault

Undercover Investigation Led to Arrests of Bradenton Area Chiropractors

According to ABC Action News, an undercover investigation led to the arrests of two Bradenton area chiropractors and other staff. Detectives say chiropractors Richard Tambe and Yusef Barnes, along with chiropractic assistant Johncina Harrell, performed a fraction of the treatments listed on insurance claims and were billing for treatment never rendered to patients.

The arrests and undercover investigation took place at the Back on Track clinic in Bradenton, Florida. According to the arrest report, all three were booked at the Manatee County Jail on insurance fraud, a third degree felony. Tambe faces 12 counts. Barnes is charged with 8 and Harrell is charged with 13 counts. If convicted each suspect faces as much as 5 years in prison.

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Filed under Florida, Insurance, Insurance Claims, Insurance Fraud, Uncategorized

Sunny South Florida, Out-of-State College Students and the question of Vehicle Insurance Coverage

Spring Break, a time where college students from all over the Country flock down to Florida, known by many as the “Spring Break Capital of the World”, looking to have some fun in the sun.

Florida has many Universities, Colleges and other institutions of higher learning that welcome students from other States to attend.

So the question is, does an out-of-state student who attends University or College in Florida for 2 or 4 years now become a resident of Florida because they have decided to live in Florida during this time? Is that out-of-state student now required to register and license their out-of-state vehicle in Florida and obtain the minimum Florida automobile insurance coverage on that vehicle which is $10,000.00 in Personal Injury Protection and $10,000.00 in Property Damage Liability?

Well yes and no.

If the out-of-state student is planning to domicile themselves in Florida then they are required to license their vehicle in Florida and obtain the minimum insurance in order to operate that vehicle on the roads and highways of the State.

However, if the student maintains their residence in another State while they are enrolled as a full-time student in an “institution of higher learning”, then they are exempt from licensing their vehicle and obtaining the minimum insurance on that vehicle during the duration of their enrollment, as long as they have complied with the licensing and insurance requirements of the State for which they are a resident. One less thing for parents to worry about when they watch their babies leave the nest for the first time.

However, what constitutes an “institution of higher learning”.

The Merriam-Webster Dictionary® defines this term as “a college or university”. But what about a trade school, vocational school or cosmetology school? The Federal Government generally defines an ”institution of higher education” as a public or nonprofit educational institution who only admits students who have a high school diploma or have a recognized equivalent certificate such as a General Educational Diploma (GED); is accredited or has pre-accreditation status; awards a Bachelor’s Degree or a 2-years Associates Degree; or, any school that provides not less than a 1-year training program beyond High School, to prepare students for gainful employment in a recognized occupation.[1]

These are inquiries that an insurance company must properly investigate in an automobile accident claim involving a nonresident student in order to determine whether they would be exempt from maintaining the minimum Florida insurance on their vehicle while in Florida or if the insurer may be required to extend that student the minimum insurance under Florida law.

So would your insured qualify for the exemption as a nonresident student?

This article is not intended 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. The content provided is intended to provide information of general interest to the public and is not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific law issues that requires attention.

For additional information, please contact Stephen Mellor of Roig Lawyers at 954-354-1541 or by email at smellor@roiglawyers.com. Stephen G. Mellor is a partner in the Deerfield Beach office of Roig Lawyers who primarily focuses on out-of-state policy claims for insurance carriers. 

[1] 20 U.S. Code § 1001

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Filed under auto insurance, Claims Handling, Florida, Insurance, Insurance Claims, Insurance Defense, Personal Injury Protection, PIP, PIP/No Fault

UPDATE: Sixth Person Found Guilty in Unlicensed Chiropractic Clinics Scam

A Naples man convicted of committing mail fraud back in September of 2016 has been sentenced to 14 years in prison. According to the Naples Daily News, Nesly Loute, was also ordered to pay restitution of almost $2.15 million to the insurance companies.

Loute and five others plead guilty and were convicted of operating five unlicensed chiropractic clinics and fraudulently billing auto insurers for Personal Injury Protection benefits.

Click here to view the full article. (Previous post)

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Filed under auto insurance, Auto Insurance Fraud, Florida, Insurance Fraud, Personal Injury Protection, PIP, PIP/No Fault, Unlicensed Clinics

Trooper Fired and Arrested for Helping Friend Cover Up Crash

Florida Highway Patrol Trooper David Casillas was arrested on Tuesday, February 28th and charged with organized fraud, filing a false insurance claim and official misconduct after trying to help a friend cover up a traffic crash that occurred in June of 2015. FHP fired Casillas in January as a result of the investigation which lasted over a year.

During the investigation, it was discovered that Casillas had written a false report for a bogus insurance claim submitted by his friend, dentist Jesus Del Valle. The insurance claim was submitted as a result of damage the dentist had done to his vehicle when he sideswiped a landscaping crew and kept driving.

Del Valle’s crash left Yoel Montero, a gardener with Lewis Tree Service, with a traumatic head injury and severe injuries to his right leg. The false insurance claim alleges that the accident happened a week later than it actually happened and that he had crashed the SUV into a palm tree instead of a landscaping crew.

The key to breaking the case was the fact that Del Valle’s 2015 Land Rover needed a new passenger-side mirror which could only be ordered from Range Rover manufacturers. Only one such had been sold in that time period and it was to Del Valle’s mechanic (and friend) Ariel Perera who performed the repair on his vehicle. Perera also allegedly submitted inflated invoices to Del Valle’s insurance company as well as charged the company for replacement parts that were never actually replaced. He is also facing charges with Del Valle and Casilla.

Click here to read the full story.

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Filed under Auto Insurance Fraud, Florida, Insurance, Insurance Fraud, Miami-Dade County

Will You Have Coverage When You Cross The Line?

Is an automobile insurance company required to extend Florida Personal Injury Protection (PIP) benefits to an insured who resides in another state?

Well yes and no.

An automobile insurer who sells automobile insurance policies in Florida and the nonresident insured’s state is required to extend the minimum Florida Personal Injury Protection (PIP) benefits of $10,000.00 to the insured if they are involved in a motor vehicle accident in Florida, but only if they qualify under Florida law.

To qualify, the nonresident insured’s vehicle must have been physically located in Florida for 90 nonconsecutive days out of the previous 365 days from the date of the accident. By nonconsecutive days, it means that the insured vehicle could leave Florida and re-enter and still qualify for Florida PIP benefits if the vehicle has been in Florida for longer than 90 days throughout that preceding year.

An insurer is not required to extend the $10,000.00 in Florida PIP benefits to a nonresident insured whose vehicle is not in Florida for longer than 90 nonconsecutive days out of the previous 365 days from the date of the accident.

Most if not all automobile insurance policies have an “Out-of-State Coverage” provision which will detail that insurer’s obligation to comply with a State’s minimum insurance requirements if their nonresident insured becomes subject to the insurance laws of that State. However, some insurance contracts make it the responsibility of the nonresident insured and not the insurer to purchase the required minimum Florida PIP coverage if they plan to stay in Florida for longer than 90-days.

An insurer is not required to extend additional Florida PIP benefits to a nonresident insured that enters Florida and whose insurance policy meets the States minimum PIP or No-Fault requirements.

For Example:

The New York Automobile No-Fault Law requires each insured to carry a minimum of $50,000.00 in No-Fault/ PIP benefits. Thus, if a New York resident drives their vehicle into Florida and is involved in a motor vehicle accident, then they will receive the $50,000.00 in New York PIP benefits as this is greater coverage than the minimum $10,000.00 in PIP benefits which is required under Florida law.

This article is not intended 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. The content provided is intended to provide information of general interest to the public and is not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific law issues that requires attention.

For additional information please contact Stephen Mellor of Roig Lawyers at 954-354-1541 or by email at smellor@roiglawyers.com.

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Filed under Auto Insurance Fraud, Florida, Insurance, Insurance Claims, Personal Injury Protection, PIP/No Fault

Chiropractor’s Challenge To ‘PIP’ Law Kicked Back By Appeals Court

In a 14-page ruling on Wednesday, February 15th, the 3rd District Court of Appeal upheld part of a 2012 overhaul of the state’s personal-injury protection auto insurance system that limits No-Fault (Personal Injury Protection) benefits to $2,500 for individuals who were not diagnosed with an emergency medical condition. The appeals court overturned a judge’s decision in a Miami-Dade County court citing arguments that the 2012 law overhaul was intended to help prevent fraud in the PIP insurance system, but was unconstitutional.

The ruling was in response to chiropractor Eduardo Garrido’s legal victory against Progressive American Insurance Company. Garrido was seeking a determination that the insurer should pay up to the policy limit of $10,000 in the absence of diagnosis that the patient suffered an emergency medical condition as the result of an automobile accident. He also challenged that it was unconstitutional to bar chiropractors from being able to diagnose patients with having suffered an emergency medical condition. The chiropractor treated a patient after an accident in 2013 and submitted invoices to Progressive who only paid $2,500 of the $6,075 billed. According to Progressive, there had been no determination, other than Dr. Garrido’s, a chiropractor, that the patient suffered an emergency medical condition.

Click here to view the full story.

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Filed under FL Legislation, Florida, Insurance, Insurance Claims, Insurance Defense, Miami-Dade County, Personal Injury Protection, PIP/No Fault

Florida Supreme Court Allstate Fee Schedule Litigation: Shall We Read The Tea Leaves?

The Florida Supreme Court recently heard oral argument in Allstate Insurance Company v. Orthopedic Specialists, No. SC15-2298. At issue was an appeal of a ruling that it wrongfully limited its reimbursements under Medicare fee schedules for motorists’ personal injury protection (PIP) claims.

Allstate’s policy language has been found to be exceedingly clear and concise by the majority of appellate courts across the state. A ruling affirming the Fourth District Court of Appeals decision would only serve to blindside Florida’s citizens with additional bills for costly co-payments while also limiting the amount of coverage available to them.

While we wait for a final opinion, industry professionals have been closely watching the court for any and all clues. Politics of the high court aside, what “shall” we analyze to determine how the justices will rule?

One such clue seems to be overlooked, yet is hiding in plain sight. On the very day that the court heard oral argument in Allstate v. Orthopedic Specialists the court issued a Per Curiam Opinion amending the Florida Rules of Civil Procedure in which the word “shall” was stricken over 200 times. See In Re: Amendments to the Florida Rules of Civil Procedure No. SC16-155. Ironically and perhaps persuasively, the court writes unanimously that “[t]he amendments shall become effective January 1, 2017, at 12:01 a.m.” (emphasis mine.)

More recently, numerous Per Curiam Opinions amending various procedural and administrative rules have been issued. They have seen the court continue to favor “shall”. Amendments to the Rules of Criminal Procedure, Rules of Appellate Procedure, Code of Judicial Conduct and Small Claims Rules did not remove any “shall” provisions.

Pouring over minor amendments by the high court with no clear answer, perhaps we are left to channel Judge May’s epic dissent in the Fourth District Court of Appeals Opinion in which she found Allstate’s policy language to be unambiguous and compliant. While accusing the medical providers of leading the majority down the yellow brick road she writes frustratingly, “As the Pope once asked Michelangelo during the painting of the Sistine Chapel: “When will there be an end?”

We “shall” know soon.

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Filed under Auto Insurance Fraud, FL Legislation, Florida, Florida Supreme Court, Fourth District Court of Appeals, Insurance, Insurance Claims, Personal Injury Protection

Two Pharmacies in Florida to Pay $750k for False Billing

U.S. Attorney’s Office, Middle District of Florida announced that Lemon Bay Drugs North, Inc. in North Port, FL and Brooksville Drugs, Inc. operating in Brooksville, FL have agreed to pay a total of $750,000 to the government to resolve allegations that the pharmacies violated the False Claims Act.

Both pharmacies are managed by Benzer Pharmacy Holding LLC and are owned by Alpesh Patel.

The allegations were that Lemon Bay and Brooksville Drugs provided Medicare and Medicaid patients generic versions of certain medications, but charged Medicare and Medicaid for the brand name versions of those medications. These allegations were initiated in a lawsuit filed by a whistleblower who was a former pharmacy technician who worked at Lemon Bay Drugs. The whistleblower will receive $142,500 as her share of the recovery.
This investigation was handled by Assistant U.S. Attorney Kyle S. Cohen with assistance from the Department of Health and Human Services – Office of Inspector General, the Defense Criminal Investigative Service, the FBI, the Florida Medicaid Fraud Control Unit, the North Port Police Department, and the Sarasota County Sheriff’s Office.

According to the Department of Justice, the claims resolved by the settlement are allegations only, and there has been no determination of liability.

Click here to view the full story.

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Filed under Florida, Health care, Insurance, Insurance Fraud

United States Settles False Claims Act Allegations Against Orthopedic Surgery Practice For $4,488,000

According to The U.S. Attorney’s Office, Middle District of Florida, Southeast Orthopedic Specialists (SOS) has agreed to pay the government $4.488 million to resolve allegations that it violated the False Claims Act.

The claims against SOS arose from the company billing federal healthcare programs for services that were not medically necessary or reasonable. Specifically, the United States contended that SOS sought reimbursement for millions of dollars of healthcare claims that were questionable.

This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative.

The claims resolved by the settlement are allegations only and there has been no determination of liability.

Click here to view the full story.

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Filed under False Claims Act, Florida, Health care, Insurance, Insurance Fraud, Middle District of Florida