ZALMA’S INSURANCE FRAUD LETTER – MAY 1, 2020

Read the full text of the May 1, 2020 ZIFL at https://lnkd.in/g9wwKHd
I’m Not a Carjacker – I was Only Helping an Insurance Fraud
Positing one of the most ridiculous defenses and ground for appeal, Dajuan D. Bowie (the “Defendant”) after he was convicted of car jacking and armed robbery, claimed he was not truly a criminal because he was fooled into believing that he was helping commit insurance fraud, forgetting that insurance fraud is also a felony.
In People of The State of Michigan v. Dajuan Deran Bowie, No. 347555, State of Michigan Court of Appeals (April 2, 2020) Defendant appealed his jury trial convictions of carjacking, armed robbery and unlawfully driving away an automobile (UDAA). Defendant was sentenced to 15 to 30 years’ imprisonment for carjacking, 15 to 30 years’ imprisonment for armed robbery, and 3 to 5 years’ imprisonment for UDAA. The trial court also ordered defendant to pay $2,034 in court costs.
BACKGROUND
On August 26, 2017, Levander Lawson (Lawson) was leaving a liquor store located in Detroit, Michigan. After Lawson entered his vehicle, Nicholas Robinson (Robinson) entered through the passenger door, pointed a gun at Lawson, and instructed Lawson to give him the car keys. Defendant entered the backseat of the vehicle and instructed Lawson to lean toward the steering wheel and took Lawson’s wallet out of his back pocket. Robinson told Lawson to get out of the vehicle, and Lawson complied. After Robinson and defendant drove away in Lawson’s vehicle, Lawson went back in the liquor store and called the police. Lawson later identified Robinson and defendant in a photographic lineup, and they were arrested.
Prior to trial, the prosecution sought to introduce evidence of other-acts evidence. Specifically, the prosecution notified defendant that it intended to use evidence of defendant’s previous carjacking conviction. Defendant responded arguing that evidence of defendant’s previous conviction “would only be used to show the defendant propensity [sic] to carjack people,” and that this “evidence only serves to inflame the jury, confuse the issues, and make the defendant look like a bad man.”
Defendant testified that although he participated in the carjacking, he thought it was an agreed on insurance fraud, alleging that he was “duped into a carjacking” by Lawson and Robinson. Following this testimony, the assistant prosecutor examined defendant and inquired whether he pled guilty to carjacking in 2011, to which defendant denied committing the crime but asserted he pled guilty “out of fear.”
ZIFL OPINION
The Defendant’s conviction was properly affirmed. To argue that he should be excused from his armed robbery conviction because he was willing to – and thought he did – participate in an insurance fraud with the victim (whose cash he took while pointing a gun at the back of the victims head) was ridiculous and discounted by the jury as it reached its unanimous verdict.
Barry Zalma

Insurance Fraud Conviction Grounds for Deportation

No Viable Excuse for Convicted Green Card Holder not to be Deported
 
After a conviction for insurance fraud, among other things, Omar Osman Mohamed (“Mohamed”) brought a petition for a writ of error coram nobisto the USDC in New York to prevent his deportation in Omar Osman Mohamed v. United States Of America., 18cv11193 (DLC), S8 06cr0600-44 (DLC), United States District Court Southern District Of New York (March 30, 2020).
A writ of error coram nobis is an extraordinary remedy. It is available only when habeas relief is unwarranted because the petitioner is no longer in custody.
ZIFL OPINION
Insurance criminals are deceptive and devious felons. Mohamed was, without doubt deceptive and has been using the courts of the United States to avoid the well deserved deportation. As a refugee he misused the courtesy provided to him by the United States by honoring it with criminal activity. He was ordered deported and he continues to abuse the United States by bringing frivolous habeas corpus and error corum nobis petitions and appealing the order of the court that required him to be deported. The immigration and refugee adjudication process is failing and he is still in the country able to commit more crimes while the United States must continue appearing in court to defeat his spurious court actions. The country needs good, hard working, honorable immigrants and refugees not people who abuse our laws.
Barry Zalma Speaks at Your Request  
A speaker on insurance, insurance claims handling, and insurance for any event at a reasonable cost at your location or by video. Go to Barry Zalma Speaks at Your Request click on link for details. Call 310-390-4455 or zalma@zalma.com
Claiming Total Loss When Evidence Does Not Support Claim Can Be a Fraudulent Act
Appraisal Inappropriate When Coverage Issues Must Be Resolved
Plaintiff Kathy Cox sued Defendant State Farm Fire and Casualty Company (“State Farm”) for breach of contract, appraisal, and statutory interest. Plaintiff alleges Defendant failed to pay her the full value of an insurance claim for a fire that damaged her residence.
In Kathy Cox v. State Farm Fire and Casualty Company v. Andrew Harms, Case No. 19-12235, United States District Court for The Eastern District of Michigan Southern Division (April 16, 2020) the court dealt with a third-party complaint against Plaintiff’s son, Andrew Harms. Defendant alleged Harms was negligent in overloading an electrical circuit while running an illegal marijuana grow operation, causing the fire in Plaintiff’s residence.
Plaintiff moved for summary judgment, asking the court to order appraisal of the property’s damage. Harms also moved for summary judgment on Defendant’s negligence claim. State Farm opposed both motions.
Other Insurance Fraud Convictions

Husband Stabbed 40 Times by His Wife and Brother-In-Law for Insurance Caught Decades Later

Howard Pilmar was a wealthy Manhattan entrepreneur with several businesses; he was viciously stabbed to death at his headquarters not far from the Empire State building.
On March 22, 1996, his body was found on the floor of his office. He had been stabbed over 40 times, with many of the wounds coming after he was already dead.
Police believed the killer knew the victim as there were no signs of false entry. The security guard had gone home for the night, which suggested the killers knew his routine. Finally, there were $200 left in his wallet, meaning robbery could be ruled out as a motive.
Police suspected his wife, Roslyn Pilmar, was the killer, and that she was aided and abetted by her brother Evan Wald, but they lacked sufficient evidence to make an arrest. It would later transpire that Roslyn was in trouble with a former employer, she had embezzled a large amount of money. She was caught stealing $160,000 from her dentist employer and fell into debt as a result.
When the police interviewed her brother Wald, they noticed his left hand was covered in cuts. A lack of evidence with no murder weapon and no witnesses meant the police were unable to build a case against the pair.
When the police put up posters near Howard’s old businesses requesting help from the public surveillance footage spotted Wald removing them. Roslyn Pilmar and Evan Wald were arrested over 20-years after the murder. Eventually, after over two decades had passed, the family’s nanny came forward with information with a vital piece of evidence that led to Roslyn and Wald being arrested. Prosecutors argued that Roslyn and Wald had plotted to murder Howard and then claim a $1.2 million life insurance policy.
It transpired that Roslyn and Howard had been having marital problems, and Howard had sought advice from a divorce lawyer. In the meantime, Wald, who was an employee of Howards, had come to resent his brother-law, believing that Howard over criticized him.
Roslyn and Wald were convicted of second-degree murder and sentenced to 25-years to life in prison.

Attorney Agrees to Plead Guilty to A String of Crimes – Bribing an FBI Agent & HIS Agent

Edgar Sargsyan, 39, an attorney with law offices in Beverly Hills, was charged April 28, 2020 with conspiracy to commit bank fraud, two counts of bribing a public official, and two counts of making false statements to federal investigators. In a plea agreement also filed April 28 in United States District Court, Sargsyan agreed to plead guilty to the five felony counts, which cumulatively carry a statutory maximum penalty of 50 years in federal prison.
Sargsyan, a Calabasas man has agreed to plead guilty to five federal offenses – one related to a credit card “bust-out” scheme, and the others related to more than $250,000 in bribes he paid to two federal agents for assistance that included sensitive law enforcement information.
In the plea agreement, Sargsyan admitted paying tens of thousands of dollars from the beginning of 2015 through early 2017 to a special agent with Homeland Security Investigations (HSI) and a special agent with the Federal Bureau of Investigation.
Sargsyan paid the HSI agent at least $32,000 in checks and at least $45,000 to $50,000 in cash in return for assistance that included the HSI agent searching law enforcement databases to corruptly obtain information that he passed to Sargsyan, according to the plea agreement. The HSI agent also altered a Department of Homeland Security database to make it “more likely” that a foreign national who was a client of Sargsyan’s law firm would be allowed to enter the United States. In another corrupt act detailed in the plea agreement, the HSI agent prepared a document on HSI letterhead in an unsuccessful attempt to have one of Sargsyan’s relatives from Armenia admitted into the United States.
Sargsyan also admitted he paid the FBI agent monthly cash bribes of up to $10,000 beginning in 2015 in exchange for the agent providing “protection,” which included running queries on law enforcement databases and warning Sargsyan to “stay away” from certain individuals who were the targets of criminal investigations. The agent, who worked out of the FBI’s San Francisco Field Office, accepted the cash payments on trips to Southern California, where he stayed at luxury hotels that were paid for by Sargsyan. The FBI agent also accepted from Sargsyan a $36,000 racing motorcycle as a “bonus” for running database checks on a particular person. Sargsyan also gave the FBI agent a $30,000 cashier’s check that was made to appear to be a payment to the agent’s business, according to court documents.
Health Insurance Fraud Convictions

Laboratory Agrees to Pay Up To $43 Million To Resolve Allegations of Medically Unnecessary Tests

Genova Diagnostics Inc., a clinical laboratory services company based in Asheville, North Carolina, has agreed to pay up to approximately $43 million to resolve allegations that it violated the False Claims Act, including claims that it billed for medically unnecessary lab tests, the Department of Justice announced April 27, 2020.
The settlement resolves allegations that Genova: (a) improperly submitted claims to Medicare, TRICARE, and the federal employee health program for its IgG allergen, NutrEval and GI Effects lab test profiles because the tests were not medically necessary, (b) engaged in improper billing techniques, and (c) paid compensation to three phlebotomy vendors that violated the physician self-referral prohibition commonly known as the Stark Law. The Stark Law is intended to ensure that physician referrals are determined by the medical needs of patients and not the financial interests of physicians.
Under the settlement, Genova has agreed to pay approximately $17 million, through the surrender of claim funds held in suspension by Medicare and TRICARE, plus up to an additional $26 million if certain financial contingencies occur within the next five years, for a total potential payment of up to $43 million.
Contemporaneous with the civil settlement, Genova entered into a five-year Corporate Integrity Agreement (CIA) with the Department of Health and Human Services Office of Inspector General. The CIA requires, among other things, that Genova establish and maintain a compliance program with specific requirements and that it engage an independent review organization.
The agreement resolves allegations brought by Darryl Landis under the qui tam, or whistleblower, provisions of the False Claims Act. The False Claims Act permits private citizens to bring a lawsuit on behalf of the United States for fraud and to share in any recovery. The settlement provides for a payment of up to approximately $6 million to Dr. Landis.
The lawsuit resolved by this settlement is captioned United States ex rel. Darryl Landis, M.D. v. Genova Diagnostics, Inc., et al., No. 1:17-cv-341 (W.D.N.C.). The claims resolved by the settlement are allegations only, and there has been no determination of liability.

Harvard University Agrees to Pay Over $1.3 Million To Resolve Overcharging NIH Grants

Harvard University has agreed to pay $1,359,791 to resolve allegations that Harvard’s T.H. Chan School of Public Health (HSPH) overcharged certain grants funded by the National Institutes of Health (NIH) and the Health Resources & Services Administration (HRSA). This settlement resulted from Harvard’s self-disclosure of issues that it identified on NIH and HRSA grants by a particular professor and her team between at least 2009 and 2014.
Colleges and universities receiving federal grants are required to accurately track their time and effort and only charge grants for time and effort that employees spent working on those grants. Overstating time and effort spent on grants can result in awarding agencies (in this case NIH and HRSA) paying more than is justified.
The government contends that the HSPH professor, Donna Spiegelman, and her team overstated the time and effort spent working on certain NIH grants for which they provided support (and where they were not principal investigators or key personnel). The overcharges were associated with statistical analysis support that the professor and her team provided to other HSPH professors on grant-related research. The government alleges that Professor Spiegelman and her team inappropriately charged their time and effort by evenly distributing their time across all grants for which they provided statistical support, without accurately accounting for the time they actually spent on particular grants. The government further alleges that Professor Spiegelman overstated a portion of her time and effort on a HRSA-funded President’s Emergency Plan for AIDS Relief (“PEPFAR”) grant, on which she was key personnel. As a result, between 2009 and 2014, Professor Spiegelman and her team allegedly overcharged certain NIH and HRSA grants by approximately $1,359,791.
This settlement also resolves allegations that HSPH knew or should have known that the manner in which Professor Spiegelman, and those working under her direction, were charging time and effort had resulted in or would result in overcharges to these NIH grants. HSPH did not timely review Professor Spiegelman’s historical timekeeping to determine whether she and her team had overcharged grants, despite questions being raised for several years about these timekeeping practices.
Since Harvard disclosed these potential overcharges to NIH and the U.S. Attorney’s Office in 2016, it investigated the potential overcharges by the professor and others at HSPH, disclosed its findings, and worked cooperatively to explain the overcharges. In addition, Harvard has put in place additional internal controls and safeguards aimed at preventing overcharges from occurring in the future.

Dominican National Sentenced for Health Care Fraud

Martha Martinez Lara, 48, previously admitted to the court that in August 2015, she applied for Medicaid benefits in Rhode Island using a stolen identity, date of birth, and Social Security number of another person. Lara’s application for Medicaid coverage was approved, and from approximately September 2015 through January 2019, she obtained RIte Care benefits totaling $11,288.46.
Lara, a Dominican national in the United States illegally, who admitted to fraudulently gaining access to Medicaid benefits with the use of a stolen identity and Social Security number, was sentenced today to two years and one day in federal prison.
An investigation by Homeland Security Investigations agents determined that the identity and Social Security number used by Lara belonged to a person living in Puerto Rico who told investigators that she never lived nor visited Rhode Island.
Lara, who was arrested on August 1, 2019, pleaded guilty on December 2, 2019, to an information charging her with false representation of a Social Security number, aggravated identity theft, and health care fraud.
Lara was sentenced April 27, 2020 by U.S. District Court Chief Judge John J. McConnell, Jr., to 24 months in federal prison, one year supervised release, and ordered to pay restitution in the amount of $11,288.46.

 

 Read the full article here.

Consider Books to Show Your Appreciation to Your Insurer Clients or Claims Employees
Many insurers refuse to allow their employees to receive gifts from vendors.
If you wish to thank your insurance company clients for allowing you to represent their interest or if you wish to honor your claims personnel it is time to give them something that will be useful to them throughout the coming year and that will not offend insurer’s rules to avoid attempts to extort clients for business from insurer employees.
Videos describing important insurance issues described by Barry Zalma and available to anyone who views or subscribes to the YouTube account. Issues include insurance fraud, definition of insurance, insurance as a contract of personal indemnity, millions for defense and not a dime for tribute and the tort of bad faith.

Read the full article here.    

New and Now Available from the Zalma Insurance Claims Library
The Insurance Examination Under Oath Second Edition

A Tool Available to Insurers to Thoroughly Investigate Claims and Work to Defeat Fraud

A Tool Available to Insurers to Thoroughly Investigate Claims and Work to Defeat Fraud.
The insurance Examination Under Oath (“EUO”) is a formal type of interview authorized by an insurance contract. It is taken under the authority provided by the agreement of the insurer, when he, she or it acquires a policy of insurance, to submit to a condition of the insurance contract that compels the insured to appear and give sworn testimony at the demand of the insurer. Failure to appear and testify is considered a breach of a material condition.

Read the full article here. 

Books

The Zalma on Insurance blog has posted over 2850 digests of insurance appellate decisions and other important insurance materials and articles published five days or more a week and are available at https://zalma.com/blog.
The videoblog is adapted from my book, Zalma on Insurance Claims available at the Zalma Insurance Claims Library

About Barry Zalma

An insurance coverage and claims handling author, consultant and expert witness with more than 48 years of practical and court room experience.
This entry was posted in Zalma on Insurance. Bookmark the permalink.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.