Tag Archives: insurance

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.

Click here for full story.

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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

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

Former Mayor of Tavares, FL Admits to Committing Insurance Fraud

According to WFTV Action 9 News, Robert Wolfe, former Tavares Mayor admitted to committing insurance fraud as part of a plea deal he made with the state. Wolfe was arrested in July after investigators found that Wolfe had reported to the insurance company that he had rented a home for $2,350 a month and had to board his dogs for $1,800 a month due to a leak in his home that needed to be repaired. However, investigators found that Wolfe never moved into the rental.

Wolfe will be placed on probation for 18 months and has been ordered to pay all investigative and court costs. He was also removed from his mayoral seat in July and has since resigned. Once Wolfe completes the 18 month pretrial intervention program, charges will be dismissed.

Click here to view the full story.

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Filed under Florida, Insurance, Insurance Fraud

Andrew v. Matthew: The Evolution of Investigative Tools in Insurance Investigations

I am sure right now many of our insurance carriers are out there running themselves ragged, trying to quickly and efficiently adjust the thousands of claims that are pouring in from Hurricane Matthew.

As the dust settles, I want to remind you of all the great resources and tools you have to investigate and adjust claims that were not available during the time of Hurricane Andrew. Although there are many, the most impactful are cellphones, portable computers and trade-specific tools of laser distance meters, moisture meters and thermal imaging devices.

Clearly, we have come a long way from the time of paper files, pay phones and disposable cameras. During Hurricane Andrew, if you wanted to review a prior claim file, you would need to retrieve it from storage or an archive. If you wanted to make an appointment to inspect the property, you would need to leave messages for the insured at their home or office, and wait for them to call you back at the office. Finally, if you wanted to take pictures of the damage, you would have needed to use a disposable camera (which date back to 1986) and hoped you captured the images you needed.

The most significant technological advancement we have at our fingertips is our cell phones. Cell phones give us the ability to take photographs, take videos, record audio and otherwise document an event. As an example, the first cameras on cell phones arrived in 2000. Since then, cellphones quickly evolved into what we know today. With that in mind, ensure that the insured is asked whether they have any photographs of the property taken prior to your inspection as well as any photographs of the damaged areas prior to them being damaged.

Ask for this information early on in the claim handling, so that if it exists, it can be secured prior to a coverage decision. A photograph is worth a thousand words, and you do not want a few of those words to be “if I’d seen that …. ”

Also, be aware that pursuant to Florida Statute 626.854 (15)(c), which states in pertinent part that an insurer shall not be prevented from “timely conducting an inspection of any part of the insured property for which there is a claim for loss or damage,” you are entitled to inspect all areas claimed as damaged. As such, make sure you are asking to see just that — all damaged areas.

Tools Of The Trade
Advancements specific to the trade have been measuring tools, moisture meters and thermal cameras, to name a few. Although the spring-click tape measure was invented in 1868, it was not until the early 1990s that laser distance measures began to circulate. These electronic tape measures not only provide precise measurements, they also assist in obtaining measurements of hard to reach or unsafe areas, common in many homes after the passing of a major hurricane.

Moisture meters and thermal-imaging devices in their current form are fairly recent concepts that have significantly impacted the trade. These two items, when used together, are very effective in locating sources of leaks, water patterns and extent of moisture. The thermal-imaging device will depict a pattern of temperature differences through contrasting colors, while the moisture meter will indicate whether an item is wet or not and can even provide the percentage of wetness depending on the device.

However, please keep in mind that thermal-imaging devices only measure differences in temperature, and the manufacturers of those devices strongly suggest verifying the thermal readings with moisture meters for that very reason. A change in temperature does not equate to moisture in and of itself.

Finally, the best technological advancement for claims handling has been the portability of the computer, i.e. tablets and laptops. These portable computers were invented in 1981 and provide the ability to retain and organize the information obtained by all of the other advancements mentioned. They also allow you to carry large amounts of information regarding weather conditions, aerial photographs of insured properties and claims history.

Knowledge Base
Ultimately, the one thing that has not changed since Hurricane Andrew is that the insured continues to be your best source of knowledge. Remember that Florida Statute 626.854(15)(b) states in pertinent part that a “person acting on behalf of the insurer” should have “reasonable access at reasonable times to any insured or claimant.”

Use that reasonable access to chat with your insured about the loss while it is still fresh in their mind. Topics of interest should include the specific details of the loss, when the loss was first discovered, efforts at mitigation, and any individuals and companies that have helped with the claim. As to efforts at mitigation, make sure to ask what was done, who did it and how they did. This information will be essential to your handling of the claim to ensure all of the insured’s proceeds are used as efficiently as possible to put the home back to its pre loss condition.

Coupling your best source of knowledge with the information you secure during your claims handling and your grasp of the relevant law will be your recipe for success during the aftermath of Hurricane Matthew.

If you are in need of a quick refresher on the rights and duties included in the applicable statutes, get in touch with registered continuing education instructors who may already have this information in a course approved by the state.

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Filed under Claims Handling, Florida Statute 626.854 (15)(c), Hurricane Andrew, Hurricane Matthew, Insurance, Insurance Claims

Miami Woman Arrested and Charged in Insurance Fraud Scheme

According to the Palm Beach Post, Carmen Montalvo-Rivera of Miami was arrested and charged in Lake Worth, FL on Thursday, October 27th after investigators say she defrauded SUNZ Insurance Company. The arrest report states that Montalvo-Rivera’s shell company, Enterprises Remodeling Group Inc., used uninsured employers to do construction work. Once the job was finished, she would then cash the checks made out to the shell company in order to pay the workers in cash and severely underreport her company’s wages to the insurance company.

Montalvo-Rivera reported Enterprise Remodeling Group’s wages at $26,665 when they were actually $4,307,092.48. Her insurance premium should have been between $327,000 and $525,000 instead of the $1,796 premium she had been paying due to her fraudulent reporting.

Click here to view the full story.

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

Former Fugitive Sentenced to 37 Months for Healthcare Fraud

A Cuban national was sentenced to more than three years in prison after pleading guilty to a $2.6 million healthcare fraud against Medicare, according to the Department of Justice.

Ubert Guillermo Rodriguez, 47, pleaded guilty to conspiracy to commit healthcare fraud in March 2016. Rodriguez, who had been a fugitive since his indictment in 2013 until his arrest in 2015, was also ordered to pay $918,000 in restitution and forfeit another $918,000. When federal authorities served a seizure warrant on Rodriguez’s bank account, they seized more than $243,000.

Rodriguez owned G.R. Services Equipment & Supplies near St. Petersburg. The company was supposed to supply medical equipment to Medicare beneficiaries. Rodriguez admitted his company submitted nearly $2.6 million in false claims to Medicare from May 2013 to June 2013. During that period, Rodriguez was reimbursed for hundreds of thousands of dollars for sterile collagen dressings and negative pressure wound therapy electrical pumps. Yet those items were never prescribed by doctors or given to beneficiaries.

The case was part of the Medicare Fraud Strike Force by the U.S. Attorney’s Office of the Middle District of Florida.

Click here for entire story.

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Filed under Florida, Insurance, Insurance Fraud, Medicare, Middle District of Florida

Miami Man Gets 5 Years for Role in $2.3 Million Medicare Fraud

A Miami man who owned a consulting and staffing company was sentenced to five years in prison for his part in a $2.3 million scheme to defraud Medicare.

Carlos Rodriguez Nerey, the 45-year-old owner of Nerey Professional Services, was sentenced by U.S. District Judge Darrin P. Gayles. The judge also ordered Nerey to pay nearly $2.4 million in restitution.

After a one-week trial that ended April 1, 2016, a jury convicted Nerey of receiving kickbacks in connection with Medicare and of conspiracy to defraud the U.S. and pay healthcare kickbacks. At the trial it was revealed that Nerey accepted kickbacks for referring Medicare beneficiaries to Mercy Home Care and D&D&D Home Health Care as patients. Some of the patients didn’t qualify for home healthcare services under Medicare rules.

The investigation was part of the U.S. Attorney’s Medicare Fraud Strike Force.

Click here for the U.S. Attorney’s press release.

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Filed under Health care, Insurance, Insurance Fraud, Medicare

Federal Appeals Court Reinstates PIP Claims Suit Against HCA

A federal appeals court has revived a lawsuit against HCA Holdings charging that HCA and three of its Florida hospitals violated Florida’s Deceptive and Unfair Practices Act.

The U.S. Court of Appeals for the Eleventh Circuit’s April 26 ruling overturned a February 2015 federal court decision in the Middle District of Florida that dismissed the class action. That suit accused three HCA hospitals—Memorial Hospital Jacksonville, North Florida Regional Medical Center of Gainesville and JFK Medical Center in Atlantis—of charging unreasonably high fees for emergency radiological services covered by Florida’s Personal Injury Protection (PIP) insurance.

The four Florida residents who filed the complaint received emergency radiological services after motor vehicle accidents. They said they were billed more than other patients who received the same services. “In fact, these fees are up to 65 times higher than the usual and customary fees charged to non-PIP patients for similar radiological services,” according to the complaint.

In one example, the court’s opinion said the hospitals charged between $5,900 and $6,965 for spinal CT scans on the plaintiffs. The ruling said Medicare rates for spinal CT scans are between $213 and $220, and rates for uninsured patients go up to $3,454.

The complaint said the exorbitant rates caused the residents’ $10,000 PIP coverage to be exhausted prematurely. The complaint also accuses HCA of breach of contract as the four Floridians entered into a Condition of Admission contract that required their accounts to be paid at the hospitals’ price lists. All four plaintiffs said they weren’t provided such a price list at the time of their treatments.

Only one of the four plaintiffs was allowed to go forward with a suit against a single hospital in the 2015 ruling by U.S. District Judge James Moody in the Middle District of Florida. Moody’s ruling was overturned by a unanimous Eleventh Circuit panel consisting of Judges Beverly B. Martin, Julie E. Carnes and Senior Judge R. Lanier Anderson III. The suit was originally filed July 2014 in the Southern District of Florida.

 

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Filed under HCA, Health care, Insurance, Insurance Defense, Insurance Fraud, Middle District of Florida, Personal Injury Protection, PIP/No Fault