Monthly Archives: June 2014

Again the Supreme Court Fails to Note that the ACA is not Insurance

No Right To Compel Purchase of Insurance That Violates Religious Belief Justice Alito wrote the opinion for the majority concerning the regulations written as part of the Affordable Care Act or Obama care. Some quotes from the opinion follow. You … Continue reading

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The Art of the Interview

The Interview Is an Essential Part of Every Insurance Claim Every insurance claim begins with the interview of the person insured to learn who was involved, what happened, when it happened, where it happened, why it happened and how it … Continue reading

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Conflict Needed for Independent Counsel

Reservation Of Rights Is Not Enough for Independent Counsel Ever since the California Court of Appeal decided San Diego Federal Credit Union v. Cumis Ins. Society, Inc. (1984) 162 Cal.App.3d 358 (Cumis) insureds who received a reservation of rights letter … Continue reading

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Creative Pleading Fails to Convince

Demand for Money Not an Equitable Remedy Before the founding of the United States courts in Britain were divided into law courts (that dealt with money damages) and courts of equity (usually operated by clerics, that dealt with fairness). As … Continue reading

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Health Insurance Fraud Conviction Stands

Jail for False Health Insurance Claims Because Medicare and Medicaid pay health care providers promptly and without any inquiry into the probity of the claim health insurance fraud is a fairly easy crime to commit with little chance of being … Continue reading

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Builder’s Risk Policy Covers Damage only to Structure as Built

No Bad Faith If Actions of Insurer is Fairly Debatable Glacier Construction Co. (Glacier) appealed a district court’s order on summary judgment limiting its recovery under a builder’s risk insurance policy (Policy) issued by Travelers Property Casualty Co. (Travelers). Glacier … Continue reading

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You Must Comply With California Regulations by September 1

California Fair Claims And SIU Regulations Require Annual Training Fair Claims Settlement Practices Regulations All insurers doing business in California must comply with the requirements of California Fair Claims Settlement Practices Regulations (the “Regulations”) or face the ire of, and … Continue reading

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Not Nice To Lie to Your Insurer

Misrepresentation Of Material Fact Ground for Claim Denial After an alleged jewelry theft Allstate Property and Casualty Insurance Company (Allstate) denied a claim, filed a complaint for declaratory relief and then filed a motion for partial summary judgment. In Allstate Property … Continue reading

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MCS 90 and Interstate Commerce

Running a Personal Errand is Not Operating “For Hire” Trucks operating in interstate commerce are required to maintain federally mandated minimum insurance coverage to protect the public whether the vehicle is identified in the policy or not.  An MCS-90 endorsement … Continue reading

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The Insurance Fraud Deskbook

I am pleased to report that the American Bar Association, Tort & Insurance Section has published my newest book: “The Insurance Fraud Deskbook”. The Insurance Fraud Deskbook Barry Zalma, Esq., CFE 2014 Paperback, 638 Pages, 7×10 The Insurance Fraud Deskbook … Continue reading

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Sex Offender Can’t Get Insurance for Erectile Disfunction

Insurance is Not a Constitutional Right Insurance is a contract between an insurer and insured. It is a commercial agreement based upon the utmost good faith between the parties to the contract. No one is compelled to buy insurance. No … Continue reading

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Resident of Household Exclusion

Objectively Reasonable Conclusion Establishes Good Faith Claim Handling Eddlee Peet obtained a wrongful death judgment against his brother-in-law, Mark Doyle, who had caused the death of plaintiff’s two-year-old son, Anthony. At the time of Anthony’s death, plaintiff and Anthony’s mother … Continue reading

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Outlaw Loses

Not Insurance — But Interesting Jurisdiction Case In Outlaw v. United States – Fed.Cl. – –, 2014 WL 2767277 (Fed.Cl.), the United States Court of Federal Claims, dealt with a breach of contract claim based on the alleged breach of … Continue reading

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Only Coverage for Insured Person

Permissive User Not Intended Insured of Umbrella Policy On October 10, 2010, Levina Rice suffered significant injuries as a passenger in a one-vehicle automobile accident in Bates County, Missouri. Rice’s son-in-law, Howard Wiebe, drove the vehicle, which was owned by … Continue reading

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Diminution in Value & Insurance

Adjusting Claims Of Diminution   Since 2001 the Georgia Supreme Court decided State Farm Mutual Automobile Insurance Co. v. Mabry, 274 Ga. 498, 556 S.E.2d 114 (Ga. 11/28/2001) there has been serious concern in the insurance industry about how a … Continue reading

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Insurance Fraud & Weapons to Fight Fraud

Insurance Fraud & Weapons to Fight Fraud © 2014 Barry Zalma, Esq., CFE On June 16, 2014 I presented a talk to those attending the International Conference of the Association of Certified Fraud Investigators. The follow is taken from the … Continue reading

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Knowledge of Insurance is Required to Adequately Investigate Insurance Fraud

From The Insurance Fraud Deskbook Before insurance fraud can be understood, it is important to understand what insurance is and how it works. Politicians continue to misunderstand insurance. Insurance is not a right awarded by the Constitution to every resident … Continue reading

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For Fun

Zalma Travels   I’m in San Antonio, Texas giving a talk on Insurance Fraud to the Association of Certified Fraud Examiners, today so I send a short story from my e-book, “Heads I Win, Tails You Lose” for your enjoyment. … Continue reading

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“Insurance Fraud Deskbook” Now Available

In the twelfth issue of its 18th year of publication of Zalma’s Insurance Fraud Letter (ZIFL) Barry Zalma, on June 15, 2014, continues the effort to reduce the effect of insurance fraud around the world. This months issue indicates that … Continue reading

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Use of Vehicle

Directing a Vehicle Can Be “Using” the Vehicle The Supreme Court of Wisconsin was faced with a case of first impression – whether a police officer directing a vehicle was “using” the vehicle for purposes of uninsured and underinsured motorist … Continue reading

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Medical Services True Value

A Hospital’s Bill is not Always The Market Value of Services Rendered Anyone who has reviewed a hospital bill in detail will be astonished by the amounts charged. A $20 charge for two aspirin is not unusual. I personally dealt … Continue reading

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Timely Disclaimer Law is Limited

If Late Notice Don’t Wait to Disclaim The Long Island Lighting Company, (LILCO) was advised it had polluted certain properties. It took its time to report the losses and potential losses to its insurers who also took a great deal … Continue reading

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The Need for a Contingent or Unknown Event

No Fortuity For Wrong that Started Before Policy Insurance, as I have often repeated, only works if the facts that caused the insured to be sued, were contingent or unknown to the insured at the time the policy was acquired. … Continue reading

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Intentional Tort

Child Theft an Intentional Tort Sometimes people attempt to get insurance coverage for acts no reasonable person would expect an insurance policy that promised to indemnify the insured against fortuitous, unintended and contingent events. This is one of those situations. … Continue reading

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“Ball Tap” an Intentional Tort

Intent to Injure Not Required to Avoid Claim Children, especially in their teen years, are subject to unqualified urges to do clearly stupid things. Often, stupidity, results in intentional acts that cause unintended injury. In American Nat. Property and Cas. … Continue reading

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No Cover For Poor Workmanship

Property Damage Must Be to Other Than Contractor’s Work Liability insurance is designed to protect an insured against liability when its conduct causes damage to property of others. It is not designed to protect the insured against poor workmanship or … Continue reading

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Effect of “Assault & Battery” Exclusion

Entire Policy Must Be Read to Interpret Policy Insurance policies, contrary to the belief of some members of the plaintiffs’ bar, are nothing more than a contract that needs to be interpreted like any other contract. In so doing the … Continue reading

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Vexatious Refusal to Pay

Bad Faith Conduct Is an Issue of Fact Insurers make decisions with regard to claims based upon what they believe is a thorough investigation of the facts and application of those facts to the wording of the policy of insurance. … Continue reading

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Duty to Defend Requires Suit or Functional Equivalent

When is a Claim Is a “Suit?” The Washington state Model Toxics Control Act (MTCA), chapter 70.105D RCW, imposes strict liability upon the owner or operator of contaminated property. Such strict liability may trigger the duty to indemnify under commercial … Continue reading

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Truck or Premises – That is the Question

When “Loading & Unloading” Is Not Although Workers’ Compensation is an exclusive remedy, when the employer is also the owner of the real property that was claimed to be defective, allows an employee to sue his employer, not as his … Continue reading

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Punch In Face Not An Occurrence

Facts Establish Intent to Injure Insurance, by definition, is a contract where the insurer promises to indemnify the insured against certain identified risk of loss due to a contingent or unknown event. That is, the damage claimed must be the … Continue reading

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Fraud Increases

Zalma’s Insurance Fraud Letter In the eleventh issue of its 18th year of publication of Zalma’s Insurance Fraud Letter (ZIFL) Barry Zalma, on June 1, 2014, continues the effort to reduce the effect of insurance fraud around the world. This … Continue reading

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