Tag Archives: Allstate

Brother Duo Accused of Massive Insurance Fraud Scheme

According to Law360, on January 3rd in a 427-page state court complaint the New Jersey Department of Banking and Insurance (DOBI) and Allstate Insurance Co. have accused brothers Anhuar and Karim Bandy of masterminding a massive personal injury insurance fraud scheme in which they recruited automobile accident victims for file claims for treatment. There were several law firms and health care providers involved in the schemes as well.

The Bandy brothers had previously pled guilty in July 2015 to organizing an insurance fraud scheme in which they recruited auto accident victims as patients for their clinics and received kickbacks from attorneys and medical professionals for patient referrals.

This recent complaint against the Bandy brothers detailed a series of alleged overlapping schemes that date back to their previous conviction. DOBI Commissioner Richard J. Badolato explained, “These and similar alleged fraudulent activities increase the cost of insurance to consumers.” While DOBI is seeking a fine against the Bandy brothers, Allstate is seeking reimbursement for paid benefits paid on behalf of its customers.

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Filed under Auto Insurance Fraud, Insurance Fraud, Personal Injury Protection

Federal Agents Arrest Participants in Medical Fraud Ring

On August 28, 2016, the Sun Sentinel reported the arrest of two women and a man who were part of a South Florida ring that staged fake car crashes. The ring aimed to defraud insurance companies by charging for massage therapy and chiropractic services to victims that did not need the medical treatment.

The defendants, Guillermo Garcia, 46; Mayre Lopez, 39; and Taymi Gonzalez, 35, were said to have collected more than $1.6 million over a span of two years from different insurance companies, including Allstate Insurance Company, Geico, Infinity, Metlife, Progressive, State Farm and Travelers of Florida. They all pleaded not guilty and are currently awaiting trial.

According to the indictment filed on August 4, the ring began in December 2012 and was carried out until September 2014 in Miami-Dade and other areas of South Florida. The indictment stated that the defendants had conspired to send fraudulent information and billing through the mail to auto insurance companies for alleged medical treatment from the clinic, Rehabilitation Tomasa.

According to the indictment, Gonzalez, Lopez and Garcia not only helped prepare fraudulent claims to insurance companies to validate treatment at Tomasa but also took part in training the ‘victims’ on what they should say to insurance representatives to deflect suspicion. The indictment stated, “ Garcia, Lopez and Gonzalez would deposit the checks into bank accounts they controlled and then convert the proceeds to cash in order to pay the recruiters, accident participants and clinic employees, and to enrich themselves.”

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Filed under Florida, Insurance, Insurance Defense, Insurance Fraud

Another DCA Sides With Insurers on Fee Schedule Language

The Third District Court of Appeal recently ruled in favor of Allstate in a dispute over personal injury protection (PIP) reimbursements for medical services following an auto accident.

The Third DCA now agrees with two other appellate courts: the First in Tallahassee and the Second in Lakeland. However, as a result of a contrary ruling from the Fourth DCA in West Palm Beach, the dispute is set for oral argument before the Florida Supreme Court in September.

The dispute focuses on language in auto insurance policies that spells out if the insurer properly elected to pay medical bills based upon the Medicare fee schedules enumerated in the PIP statute. Florida courts have said the insurance policies must unambiguously elect the use of the statutory fee schedules in limiting reimbursement for PIP claims.

The Third DCA case came from five consolidated appeals. All five concerned a medical provider, as assignee of a person insured by Allstate, suing Allstate for payment of medical bills under the PIP statute. In each case the policy had identical policy language stating: “Any amounts payable under this coverage shall be subject to any and all limitations, authorized by section 627.736 … including but not limited to, all fee schedules.”

Third DCA Judge Thomas Logue, who wrote the opinion, agreed with the opinions in the other two appellate courts finding for Allstate and noted that he agreed with Judge Melanie May’s dissent in the Fourth DCA ruling. Logue disagreed with medical providers, who insisted the words “subject to” were ambiguous.

“A decision that the term ‘subject to’ is ambiguous would mean that the Judicial Code and many provisions of Florida Statutes were legally meaningless and in need of redrafting,” Logue wrote. “We decline to adopt such a counter-intuitive interpretation of a common and well-understood legal expression. The use of the phrase ‘subject to’ in the policy places the insured on notice of the limitations elected by Allstate.”

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Filed under Fla. Stat. 627.736 (2012), Florida, Insurance, Insurance Defense, Miami-Dade County, Personal Injury Protection, PIP/No Fault

Allstate battles in Appellate courts

Allstate is under fire in various courts addressing the language of its policy following the Florida Supreme Court’s ruling in Geico Gen. Ins. Co. v. Virtual Imaging Services, Inc., 141 So.3d 147 (Fla.2013). In Virtual Imaging, the Court ruled in favor of Virtual Imaging finding that GEICO had not made the election in the policy that they would use the Medicare fee schedules of Florida’s PIP statute to reimburse the medical providers.

Multiple appellate courts have been asked to address the issue of the language in Allstate Insurance Co.’s policy regarding its election to use the Medicare fee schedules to limit benefit reimbursements. The various Appellate courts are addressing the following question: “Did Allstate provide the requisite notice that it would use the fee schedule payment limitations authorized by Subsection 5(a)(2)?”

The following cases are under review throughout Florida’s Appellate courts:

Allstate v. Stand-Up MRI

Case No. 1D-14-1213

First District Court of Appeal

This case includes several consolidated county court appeals. Allstate is the Appellant, and former Judge Gary Farmer represents the Plaintiffs. The First DCA ruled in favor of Allstate in March (see earlier post titled, 1st DCA Upholds Allstate Use of Medical Fee Schedules). On April 24, the First DCA denied Appellee’s April 2nd motion for rehearing, rehearing en banc and certification.

Allstate v. Markley Chiro.

Case No. 2D-14-3818 in the Second District Court of Appeal on cert. question of great public importance

Allstate is Appellant

The case was fully briefed in February, 2015 and argument is requested.

Fla. Wellness v. Allstate

Case No. 3D-15-0151

Third District Court of Appeal

There are five consolidated county court appeals. Allstate is the Appellee. Marlene Reiss represents the Plaintiffs/Appellants. The briefing has not yet begun.

Ortho. Specialists v. Allstate

Case No. 4D-14-0287

Fourth District Court of Appeal

There are several consolidated county court appeals. Allstate is the Appellee. Former Judge Gary Farmer represents the Plaintiffs. The appeal was argued on April 14th.

Florida Wellness v. Allstate

Case No. 15-11590

The U.S. Court of Appeals for the Eleventh Circuit

The federal district court’s summary judgment order is being appealed by Plaintiff South Florida Wellness. Allstate is the Appellee. The briefing has not yet begun.

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

1st DCA Upholds Allstate Use of Medical Fee Schedules

In an opinion filed March 18, 2015, Florida’s First District Court of Appeal held that language in an Allstate Insurance Co. policy gave sufficient notice to an assignee of its election to use Medicare fee schedules to limit benefit reimbursements under a PIP policy. Stand-Up MRI of Tallahassee, an assignee of 14 named insureds, sued Allstate in county court, contending that Allstate’s alleged failure to give adequate notice was contrary to the Florida Supreme Court’s decision in Geico v. Virtual Imaging. The trial court agreed with Stand-Up MRI and certified a question of great public importance to the Appellate Court.

In Virtual Imaging, as here, an MRI provider had supplied services and then disputed the insurer’s authority to limit reimbursements under Medicare fee schedules. Pursuant to the Florida PIP statute, automobile insurers are required to provide PIP coverage for 80 percent of all “reasonable expenses” for medically necessary services.

The dispute here centers on whether Allstate’s policy language provided adequate notice of its election to limit reimbursements via the Medicare fee schedules or if, as Stand-Up MRI contends, the policy fails because it is ambiguous. Allstate points to the following language in the policy as having satisfied the Virtual Imaging notice requirement:

In accordance with the Florida Motor Vehicle No-Fault Law, [Allstate] will pay to or on behalf of the injured person the following benefits. . . .

Medical Expenses

Eighty percent of reasonable expenses for medically necessary … services. …

Any amounts payable under this coverage shall be subject to any and all limitations, authorized by section 627.736, or any other provisions of the Florida Motor Vehicle No-Fault Law, as enacted, amended or otherwise continued in the law, including, but not limited to, all fee schedules.

The appellate court agreed with Allstate, concluding that the policy gives sufficient notice of its election to limit reimbursements by use of the fee schedules. In making its decision, the court pointed to language in the policy stating that reimbursements “shall” be subject to the limitations of §627.736, including “all fee schedules.”

Section 627.736(5)(a) 2 refers to Medicare fee schedule-based limitations and provides that insurers “may limit reimbursement to 80 percent of the … schedule of maximum charges.” Thus, concluded the court, the notice requirement was satisfied by Allstate’s language limiting “any amounts payable” to the fee schedule-based limitations found in the statute.

Furthermore, the court also distinguished the language in Allstate’s policy from that found deficient in Virtual Imaging. There, the Florida Supreme Court concluded that Geico’s policy failed to “indicate in any way” that it intended to limit its reimbursement amounts using the fee schedules. Here, Allstate’s policy expressly limits reimbursements by “all fee schedules” in the statute, satisfying the Virtual Imaging notice requirement.

Stand-Up MRI also contended that Allstate’s use of the phrase “subject to . . . all fee schedules” fails to provide sufficient notice that reimbursements will always be limited by the fee schedules, arguing that “subject to” means only that Allstate had the option to limit reimbursements per the Medicare fee schedule , not that it would so limit reimbursements. The court, however, found no such ambiguity, stating that the language of the policy makes reimbursements subordinate to the fee schedule in “rather unmistakable terms.”

In sum, the court concluded that Allstate’s policy language gave legally sufficient notice to its insureds of its election to use the Medicare fee schedules as required by Virtual Imaging. The trial court’s decision was reversed and the case remanded for further proceedings.

The cases cited are listed below for reference.

Allstate Fire and Casualty Ins. v. Stand-Up MRI of Tallahassee, Case No. 1D14-1213, et al., 1st DCA Fla. (March 18, 2015).

Geico Gen. Ins. Co. v. Virtual Imaging Servs. Inc., 141 So. 3d 147 (Fla. 2013).

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Filed under Fla. Stat. 627.736 (2012), The Statutory "Fee Schedules"

Allstate to Recover Almost $1 Million in PIP Case against Dr. Sara Vizcay

In a case brought by Allstate in the Florida Middle District, the court ruled on August 1st that the Defendant’s Motion for Declaration of Mistrial was denied, the Plaintiff’s Motion for Declaratory Judgment was granted in part, and the final judgment was ordered.

Dr. Sara C. Vizcay and the seven medical clinics listed below were the Defendants in the case.

  • Best Care Medical Center, Inc.
  • Caleb Health Care, Inc.
  • Florida Rehabilitation Practice, Inc.
  • Global Diagnostic Center, Inc.
  • Personal Medical Center, Inc.
  • P.V.C. Medical Center, Inc.
  • Regional Enterprises for Health Corporation

Fraudulent billing practices and failure to comply with the licensing requirements of the Florida Health Care Clinic Act (HCCA) formed the basis of Plaintiff allegations. In a jury trial earlier this year, the jury found that each Defendant misrepresented material facts.

The court noted that the “jury unanimously found Plaintiffs proved, by a preponderance of evidence, that Dr. Vizcay failed to substantially comply with her statutory medical director duties to systematically review bills … and to ensure those bills were not fraudulent or unlawful.”

The total amount to be recovered by Allstate is $942,883.41, and Plaintiff is not obligated to pay any unpaid amounts.

The case is Allstate v. Sara C. Vizcay, M.D. et al., U.S. District Court for the Middle District of Florida, Case No. 8:11-CV-804-EAK-EAJ. Click on the link to read the August 1, 2014 Order of Judgment.

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Filed under Case Law, Insurance Fraud

Two Arrested for Related PIP Insurance Fraud

Leonardo F. Marquez Garcia of Miami and Dayleann Marie Vallejo-Ruiz of Orlando were recently arrested on charges of PIP insurance fraud.

More arrests are expected in the ongoing investigation by the Florida Department of Financial Services’ Division of Insurance Fraud, CFO Jeff Atwater announced.

Investigators found that Garcia would allegedly perform ‘initial examinations’ on victims of vehicle crashes, and then refer his patients to the Injury Rehabilitation Center, a clinic owned and operated by Vallejo-Ruiz.

Vallejo-Ruiz, a licensed massage therapist, would then have patients sign blank treatment forms which were later submitted to the insurance company to pay for treatment that was never provided. Allstate Insurance Company was billed for the alleged medical treatments supposedly provided between February 3 and March 16, 2012, on two crash victims.

Garcia also submitted his requests for payment for his initial examinations on behalf of Global Rehabilitation Center, Inc., in Miami Lakes. However, it was discovered that Garcia—an Area of Critical Needs Doctor—was not licensed to practice medicine at that facility because it was not an Area of Critical Needs clinic. Garcia was subsequently charged with the unlicensed practice of medicine for operating outside the scope of his license.

The Orange County State Attorney’s Office is prosecuting the case.  Each defendant stands to face up to 15-20 years in prison if convicted.

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Filed under Insurance Fraud

Allstate Wins $7 Million California Insurance Fraud Lawsuit

Allstate recently announced a successful outcome in the following case.

LOS ANGELES, Sept. 26, 2013 /PRNewswire/ — Los Angeles County Superior Court has ruled in favor of Allstate Insurance Company and the State of California in a lawsuit topping $7 million that ends fraudulent business and billing schemes by unlicensed medical and chiropractic personnel.

In its lawsuit, Allstate alleged Maria Miranda, Frank Rivera and LA Healthcare Management, Inc. violated the state’s Insurance Fraud Protection Act when they submitted to Allstate more than 390 chiropractic claims that were falsely generated by unlicensed and untrained personnel, or because the billed treatments did not reflect patients’ physical needs.

Judge William Fahey agreed with Allstate and ordered Miranda and Rivera to pay Allstate $3.9 million in penalties, plus $3.8 million in assessments and fees—a $7.7 million judgment.

“Submitting even one false insurance claim is more than just a bad idea—it’s fraud, and insurance fraud is a crime,” said Allstate’s California Field Vice President Phil Telgenhoff. “Fraud drives up the cost we all pay for insurance by stealing millions of dollars from insurers. This cannot and will not be tolerated in California or anywhere.”

“Allstate will fight fraud to help protect our customers and keep insurance costs down,” Telgenhoff said.

Allstate’s suit identified Miranda and Rivera as two unlicensed non-professionals operating through LA Health Care and Lynwood Health Care clinics and catering to attorneys representing people who all made claims of soft tissue injuries. The clinics are no longer in operation.

Allstate successfully argued that Miranda violated California’s Unfair Business Practices Act, claiming that—as owner of L.A. Healthcare Management, Inc.—she was solely responsible for overseeing and directing the fraudulent operation of both clinics, which included the recruitment and steering of patients, setting standard operating procedures for patient treatment regardless of medical need, and submitting false narrative reports and bills.

Other violations recognized by the judge include Miranda and Rivera practicing medicine and chiropractic without a license, operating a professional medical corporation in violation of state law and falsifying patient medical records.

This is the second multi-million dollar ruling against insurance fraud in Los Angeles Superior Court that Allstate has successfully argued within the past year.

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Filed under Case Law, Insurance Fraud

Allstate Awarded $7 Million in Medical Insurance Fraud Lawsuit in Nevada

Following a Racketeering Influenced and Corrupt Organizations (RICO) investigation that continued for nearly 10 years, the Allstate Insurance Company received a judgment of more than $7 million in the company’s first medical fraud lawsuit in the state of Nevada.

The RICO complaint was filed against chiropractor Obteen Nassiri, D.C., in 2008, in the Las Vegas Federal District Court. It also included his businesses: Advanced Accident Chiropractic Care, ONN Management, Digital Imaging Services and Digital X-Ray. The Chiropractic Physicians’ Board of Nevada subsequently revoked Nassiri’s license as a result of the filing.

Nassiri’s alleged deceit of the insurance provider began in 2003. The suit charged that the defendant exhibited an overall pattern of illegal and fraudulent activity including: charging for treatment he did not provide, exaggerating clinical findings, submitting improbable diagnoses, providing unnecessary and excessive treatment, grossly misrepresenting billing, and making inappropriate referrals.

The case also accused Nassiri of operating a practice that referred patients to his clinics for unnecessary medical consultations and expensive diagnostic work to increase his revenue and profit.

In addition, the jury found Nassiri’s spouse, Jennifer Nassiri, liable for negligent misrepresentation in the overall fraudulent scheme to harm Allstate.

Allstate spokesperson Chelci Vaughan said in a news release statement, “Medical insurance fraud affects all policyholder’s premiums, and it’s not fair for consumers to pay higher rates for criminal behavior. We are committed to protecting our customers from being victimized by this type of fraud.”

The total judgment against the defendants included an award to Allstate for $3.59 million in compensatory damages, $2.51 million in punitive damages, and $1 million in pre-judgment interest. As a result of Allstate’s trial victory, the company is also pursuing more than $1 million in attorney’s fees and costs.

The monetary award means Allstate will recover money for the settlement of more than 150 auto accident claims that involved fraudulent costs. Allstate sought recovery against each defendant for their violation of both Nevada state and federal law based on a pattern of fraudulent behavior.

According to Allstate, the judgment should put unscrupulous providers on notice that the company maintains a zero-tolerance approach and will continue in the fight against insurance fraud.

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Filed under Case Law, Insurance Fraud