Quote of the Issue - Barry Zalma, Inc. | Insurance Claims ... · 10/1/2017  · faith, and insurance fraud consultant. I will continue to publish, twice a month, Zalma’s Insurance

The Once & Future Lawyer

Receiving the Legend Award

Zalma’s Insurance

Fraud Letter

The Essential Resource For The Insurance Fraud Professional

A ClaimSchool ™ Publication, Written by Barry Zalma, Esq., CFE © 2017 ClaimSchool, Inc. & Barry Zalma

Volume 21, No. 19October 1, 2017

Go to Zalma Books – E-Books and Articles by Barry Zalma –http://www.zalma.com/zalmabooks.htm Go to my: Zalma’s Insurance 101 at http://www.zalma.com/videoblog Go to: Insurance Law Commentary by Barry Zalma at http://zalma.com/insvideo

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Go to my blog: Zalma On Insurance at http://zalma.com/blog

Quote of the Issue

“The love of liberty is the love of others; the love of power is the love of ourselves.”

William Hazlitt

October 1, 1979 - 2017 Another Anniversary

Thirty eight years ago today I left the world of the employed and became an entrepreneur by opening my ownlaw firm that was incorporated shortly thereafter as Barry Zalma, Inc. When I opened for business on October1, 1979, I had no clients other than my sister, and no certainty that I would have any in the future. I hadborrowed money from the bank to carry me through the first six months and was concerned about my ability topay the loan with my third child about to be born.

Much to my surprise and pleasure, on October 1, 1979, at 8:10 a.m., my friend Alan Worboys called fromLondon and provided me with my first case as an independent lawyer to represent Certain Underwriters atLloyd’s, London. He, and the Lloyd’s Underwriters he represented, showed faith in me as a lawyer andinsurance expert. My old firm wouldn’t tell Alan where I went after I resigned so he called our mutual friendand great adjuster and investigator, the late Leslie M. Schifrin, who gave him my newly installed telephonenumber. Alan is now, and will forever be, my law firm’s first client and a good friend.

From January 2, 1972 until November 2015 I practiced law in California. In November 2015 I caused my lawlicense to be placed in inactive status since I no longer had the energy or stamina to practice law and

professionally represent my clients as their lawyer. I am still a member of the California Bar but no longer have the right to representclients as a lawyer. To those of you, in addition to Alan, who have honored me by retaining me as your lawyer, thank you for a long,productive and successful legal career. I am now 75-years-old and limit my practice to consulting with lawyers and insurers concerningproperty and casualty insurance issues. I expect to continue working forever, or until I reach the century mark my mother reached beforeshe passed away, if the work of the doctors who have placed stents in my calcified arteries are successful.

I continue to be in the office five days a week. I will continue to serve as an insurance claims handling, insurance coverage, insurance badfaith, and insurance fraud consultant. I will continue to publish, twice a month, Zalma’s Insurance Fraud Letter and will publish daily tomy blog, Zalma on Insurance, that contains more than 1970 digests of recent cases. I will keep available Zalma’s Insurance 101, a videoblog based on my book Insurance Claims, a Comprehensive Guide. I will also continue to contribute to the National UnderwriterCompany’s The Zalma Insurance Claims Library, FC&S Bulletin’s, articles for the National Underwriter Company’s NationalUnderwriter Magazine and Claims Magazine, books for the American Bar Association and articles for various other insurance publicationsand create training for Illumeo.com. I will continue to publish e-books on my web site at http://www.zalma.com/zalmabooks.htm.

Thank you again for your faith in me and Barry Zalma, Inc. where I expect to continue to act as a consultant and publish books and e-books.

I hope to continue to serve you and remain available as a claims handling consultant and educator.Consultation can save you or your client thousands of dollars in the defense or prosecution of aninsurance dispute. Barry Zalma, Inc. is dedicated to help clients find a solution to an insuranceclaims dispute that is fair, intelligent, beneficial and economical.

Barry Zalma, Inc. is available to provide expert advice to individuals and their counsel. Advicefrom Barry Zalma, Inc. is indispensable to the resolution of insurance disputes. Consultation fromMr. Zalma can save you, your counsel or client hundreds of hours of investigative and legal work.

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Become a Certified Expert in Corporate Property Insurance and

a Certified Expert in Corporate Liability Insurance

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Everyone involved in insurance – either as an insurer or as an insured – requires excellence in claims handling.Businesses need to deal with insurers who have an excellence in claims-handling mandate. Insurers who wishto profit need an excellence in property and/or liability claims-handling program. Everyone in business needsan insurer who has an excellence in property or liability claims-handling program in effect.

Two comprehensive programs enabling insurance professionals to become Certified Expert in CorporateProperty Insurance and/or Certified Experts in Corporate Liability Insurance are available from Illumeo.com.

The programs are complete courses of study providing education and training to allow insurance professionals, after completing theindividual classes, to become a Certified Expert. The programs cover everything an employee, an officer, or a director of a corporationneeds to know about the need to acquire proper insurance and to resolve any claim presented by the corporation to theinsurer.

Major topics of study include, but are not limited to: the importance of insurance; how to acquire insurance andunderstand an insurance policy; the methods used by insurers to investigate claims; the various types of insurance thatcorporations need; the duties and obligations of a public adjuster; and how The full curriculum of the courses andother courses from Barry Zalma are available at http://www.ilumeo.com by entering in the search bar the word“zalma.”

If you do the Crime You Must Do the Time

Once Convicted Criminals Refuse to Accept the Sentence Rendered

People who conspire to distribute the deadly opiods with physicians who defraud insurers, Medicare andMedicaid, are vicious and responsible for many over dose deaths of those to whom the opiods are provided.When convicted and sentenced the convicted criminals try to avoid the sentence.

In United States of America v. Rickie Horvath, United States District Court District Of New Jersey, CriminalNo. 15-0400 (ES), (September 13, 2017) the USDC, New Jersey, refused to fall for the attempt.

BACKGROUND

Defendant Rickie Horvath moved for bail pending appeal. The Government opposes Mr. Horvath’s Motion.The Court declined to hold oral argument.

Horvath is a 56-year-old man suffering from multiple health impairments, including a severe heart condition. On May 25, 2016, Mr.Horvath pleaded guilty to conspiring and agreeing with others to distribute oxycodone (“Plea Agreement”). At the time of his pleaagreement, Mr. Horvath was imprisoned as a state prisoner in connection with theft and insurance-fraud charges unrelated to the federalmatter. Mr. Horvath was released from state prison on July 8, 2016, and immediately transferred into federal custody.

Mr. Horvath requested release from federal prison due to his deteriorating health condition.

The Court eventually sentenced Mr. Horvath after granting him bail for four months. In doing so, the Court adopted Mr. Horvath’sPresentence Report (“PSR”) without changes. Based on calculations in the pre-sentence report, Mr. Horvath faced an advisory guidelinessentencing range of 46 to 57 months’ imprisonment.

At the sentencing hearing, Mr. Horvath moved for a downward departure due to his medical condition and his prior confinement in UnionCounty Jail. The Court granted a downward variance and sentenced Mr. Horvath to 41 months’ imprisonment. The Court analyzed thefactors on the record at length.

On August 26, 2017, Mr. Horvath received a notice to surrender to the Bureau of Prisons (“BOP”) at ButnerLow FCI in Butner, North Carolina, on September 5, 2017. On August 28, 2017, Mr. Horvath requested thatthis Court stay his surrender for thirty days to allow him to continue to recuperate from his heart surgery andso that his anticipated application for bail pending appeal may be argued and considered by the Court.

DISCUSSION

Congress enacted the Bail Reform Act of 1984 to create a presumption in favor of post-conviction detention.Under this statute, a defendant must establish:

(1) that [he or she] is not likely to flee or pose a danger to the safety of any other person or thecommunity if released;

(2) that the appeal is not for purpose of delay;

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(3) that the appeal raises a substantial question of law or fact; and

(4) that if that substantial question is determined favorably to the defendant on appeal, that decision is likely to result in reversal or anorder for a new trial of all counts on which imprisonment has been imposed.

In addition, a defendant convicted of an offense within the Controlled Substances Act punishable by morethan 10 years must clearly show that there are exceptional reasons why such person’s detention would notbe appropriate.

Relevant here, under the third prong’s substantial-question analysis, a court must determine that thequestion raised on appeal is a substantial one, that is, it must find that the significant question at issue isone which is either novel, which has not been decided by controlling precedent, or which is fairly doubtful.To that end, a defendant must demonstrate that the issues are debatable among jurists of reason; that a courtcould resolve the issues in a different manner; or that the questions are adequate to deserve encouragementto proceed further.

Because a defendant must demonstrate that the appeal raises a substantial question of law or fact, thedistrict court must look to the applicable standard of review when assessing the third prong.

The abuse-of-discretion standard applies to both the procedural and substantive reasonableness inquiries.Furthermore

ANALYSIS

Mr. Horvath raises the following allegedly substantial question on appeal: “whether a sentence of 41 months, a significantly longer termthan any prior sentence experienced by the defendant, without adjustment for all time already served while suffering from the advancedstages of congestive heart failure and while financially unable to post a $75,000.00 bail, is excessive and fundamentally unfair.” Mr.Horvath argues that his sentence is excessive because it constitutes a “substantial increase in punishment for a low-level drug offensesimilar to any offense previously committed by Mr. Horvath.” In particular, he points out thateach of his “prior periods of detention for low-level state offenses is less than the time servedalready for the present offense (18-months combined in the Union County Jail and EssexCounty Correctional Center).”

Mr. Horvath also argues that his medical history and characteristics warrant a substantiallyreduced sentence.

The Court concluded that Mr. Horvath has not met his burden of demonstrating a substantialquestion of law or fact. As an initial matter, Mr. Horvath does not contend that his allegedlysubstantial question is novel; rather, he argues that his 41-month sentence is a “fairly debatablesentence ripe for appellate review.” The Court disagreed.

Although nearly all of Mr. Horvath’s arguments concern the substantive reasonableness of his sentence, he also contends that the Courtcommitted procedural error. As the Government correctly notes, Mr. Horvath does not explain how the Court gave “undue weight” to theSentencing Guidelines.

Without more, Mr. Horvath has failed to show that this issue—whether the district court committed procedural error constituting an abuseof discretion—is “fairly debatable.”

Mr. Horvath primarily argues that his 41-month sentence, in light of his deteriorating medical condition and prior incarceration, is“excessive and unfair.” This argument, as the Government observes, goes to whether the Court’s sentencing decision was substantivelyreasonable. Thus, Mr. Horvath must show that it is “fairly debatable” that the Court abused its discretion and imposed a sentence that noreasonable sentencing court would have imposed on him for the reasons the Court provided at the sentencing hearing.

The Court thoroughly considered and discussed his arguments over the course of two and a half hours. Moreover, the Court granted Mr.Horvath a downward variance and sentenced him below the advisory guideline range. The Court also advised Mr. Horvath that it balancedhis sentence against the sentences imposed on other members of the conspiracy.

Because Mr. Horvath cannot satisfy the four factors required by the statute the Court must deny his Motion.

ZIFL OPINION

Mr. Horvath was an evil man. He stole from insurers, Medicare and Medicaid to provide dangerous drugs to addictsunder the guise of medical treatment, was possibly responsible for the death of many users, was convicted of multiplestate and federal crimes, and now seeks mercy and a minimal sentence because he is sick. He did the crime. He askedto court to keep him from serving the time. The USDC refused to buy his argument. He must do the time.

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Books from Barry Zalma

“Insurance Law”

Quick Overview

Insurance Law is the most comprehensive, and yet practical, insurance law authority available today. Written bynationally-renowned insurance coverage expert, consultant and blogger Barry Zalma, Insurance Law introducesthe new insurance professional to the fundamental principles of insurance and provides the experienced litigatoranalyses of today’s leading insurance law decisions nationwide.

Insurance Law is the most comprehensive, and yet practical, insurance law authority available today.

This book is ideal for any professional who works in or frequently interacts with the insurance industry. Claimsprofessionals, risk managers, producers, underwriters, attorneys (both plaintiff and defense), business owners, andstudents will benefit greatly from this all-inclusive reference. It is also the perfect resource for educators andtrainers whose role requires an understanding of insurance law.

In addition to case law, the author has provided countless citations to relevant statutory, regulatory, and judicialsources which are guaranteed to kickstart your research.

http://www.nationalunderwriter.com/insurance-law.html

Additional books at the Zalma Insurance Claims Library

http://www.nationalunderwriter.com/reference-bookstore/property-and-casualty/zalma-insurance-claims-library.html

In addition the standard FC&S Online published by The National Underwriter Company now includes a Fraud Channel with the majorityof the information taken from my work on insurance fraud. It is available at http://www.nationalunderwriterpc.com/Pages/default.aspx. TheFraud Channel covers issues like: Fraud Basics, Checklists and Charts, Investigation, Ethics, Reference Materials, Fraud Of The Week, and both the full text and summaries of insurance fraud Cases.

California Workers’ Comp Division Suspends 6 Medical Providers for Fraud

The California Division of Workers’ Compensation has suspended six more medical providers fromparticipating in the state’s workers’ comp system, bringing the total number of suspended providers to 38.

The suspensions were made possible by the passage last year of Assembly Bill 1244, which requires the DWCadministrative director to suspend any medical provider convicted of a crime involving fraud or abuse of theMedi-Cal or Medicare programs or the workers’ comp system, a patient, or related types of misconduct.

DWC Acting Administrative Director George Parisotto issued orders of suspension against the followingproviders:

• Jeffrey Campau and Landen Mirallegro of Yorba Linda, co-founders of the medical equipment company AspenMedical Resources, MRI diagnostic facility LC dba Elite Diagnostics, and an MRI services company, RegionalMedical Services LLC. Campau and Mirallegro pled guilty in Orange County Superior Court on May 5 to medicalinsurance fraud for their involvement in an overbilling scheme in which they defrauded insurance companies of morethan $70 million. Along with their co-defendant, Campau and Mirallegro agreed to pay over $8 million in restitution toseveral insurers and self-insured employers, and to voluntarily dismiss liens of nearly $140 million, in the case involvingAspen Medical Resources.

• Simon Hong of Brea, a medical clinic operator who on Oct. 19, 2016 was found guilty by a federal jury in OrangeCounty of 19 counts of health care fraud, illegal kickbacks, and identity theft involving the Medicare program.

• Chi Hong Yang of San Gabriel, who pled guilty in Kern County Superior Court on Aug. 2, 2013 to conspiracy tocommit insurance fraud, involving among other things billing and obtaining payment for services not provided. Yangsurrendered his physician’s and surgeon’s certificate earlier this year.

• Rafael U. Chavez of Rancho Cucamonga, due to revocation of his certificationas a physician assistant by the Physician Assistant Board of California on June19, 2014.

• Wendell Wenneker of Napa, whose physician’s and surgeon’s certificate wasrevoked on June 2 by the Medical Board of California.

AB 1244 requires the DWC administrative director to suspend any medical provider, physician, orpractitioner from participating in the workers’ comp system in cases in which any of the followingis true: They were convicted of a felony or misdemeanor involving fraud or abuse of the Medi-Cal or Medicare programs or the workers’

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compensation system, fraud or abuse of a patient, or related misconduct; they were suspended due to fraud or abuse from the Medicare orMedicaid programs; or the provider’s license to provide health care has been surrendered or revoked.

Barry Zalma Speaks at Your Request

A speaker on insurance, insurance claims handling, and insurance for any event at a reasonable cost at yourlocation or by video. Go to Barry Zalma Speaks at Your Request click on link for details.

It’s Not Nice to Lie to Your Insurer

When an insured, operating a livery and taxi service obtains an insurance policy covering one of its vehicles as a private passenger vehicleknowing that its application for insurance was false found itself without insurance of any kind. The lies, even insuring the property in thename of a person who neither owned nor operated the vehicle was egregious and fraudulent.

In 21ST Century Insurance Company, individually, and as attorney in fact for Myriam Ledee, v. FelipeExpress; Felipe Sanchez Jr.; Felipe Sanchez Sr.; Edward Santana; Perfecto Hernandez; Lucia Hernandez; andMilton Saeteros; et al., Civil Action No. 15-7075 (FLW) (DEA), United States District Court District Of NewJersey (September 22, 2017) the USDA was asked to declare the policy void and not compel the insurer to payinnocent passengers under New Jersey’s Deemer statute.

FACTS

Following an automobile accident on the New Jersey turnpike, Plaintiff 21st Century Centennial InsuranceCompany (“21st Century” or “Plaintiff”) initiated this action (the “21st Century case”) against variousdefendants. The present dispute centers on 21st Century’s claims against Felipe Sanchez, Sr., Felipe Sanchez,Jr., and Felipe Express (collectively, the “Felipe Defendants”) for insurance fraud under the Insurance FraudPrevention Act (“IFPA”), N.J.S.A. 17:33A-1 et seq. and common law fraud, as well as its claim seeking a declaration that 21st Century hasno coverage obligations under a policy of insurance that it issued to Myriam Ledee.

The relevant 21st Century policy of insurance (the “Policy” or “21st Century Policy”) lists Myriam Ledee, an Ohio resident and the ex-wifeof Felipe Sanchez, Jr., as the named insured. Defendants Felipe Sanchez, Sr. and Felipe Sanchez, Jr. are the owners of Felipe Express, atransportation company that operates out of Silver Springs, Maryland. Felipe Express provides transportation and taxi services, for a fee, tomembers of the public between the Washington, D.C. and New York City areas, including New Jersey.

The underlying facts concerning the accident are undisputed. On March 6, 2015, Defendant Edward Santana, an employee of FelipeExpress, was driving the Van on the southbound side of the New Jersey Turnpike, during the course of his employment, when he collidedwith a vehicle driven by a representative of the New Jersey Turnpike Authority. Perfecto Hernandez and Lucia Hernandez were passengersin the Van at the time of the accident. Lucia alleges that she sustained personal injuries, requiring medical treatment, as a result of theaccident.

Ledee testified that she did not submit an application for the Policy, did not give anyone, including FelipeExpress, Felipe Sanchez, Jr., and Felipe Sanchez, Sr., permission to obtain the Policy in her name, and was notaware that the Policy had been applied for or obtained prior to the accident.

According to the testimony of Diana Yeager, an underwriting staff consultant for 21st Century, 21st Centuryconducted business in New Jersey during the relevant policy period, including the date of the subject accident.Yeager testified that during all relevant periods, 21st Century did not issue commercial policies, includingpolicies covering taxis, buses, or delivery vehicles.

The 21st Century policy specifically excluded coverage for liability arising out of the use of a vehicle for commercial purposes.

DISCUSSION

The Court found that default judgment is appropriate against the Felipe Defendants on all counts, because Plaintiff has established a primafacie case for relief.

The New Jersey Legislature enacted the IFPA to “confront aggressively the problem of insurance fraud in New Jersey.” N.J.S.A. 17:33A-2.The Legislature added the crime of “insurance fraud” in 2003, as part of a “a comprehensive set of solutions to the automobile insuranceavailability and affordability challenges facing insurers, consumers and regulators in New Jersey.”

Unlike common law fraud, proof of fraud under the IFPA does not require proof of reliance on afalse statement or resultant damages. “The applicable burden of proof to prove a violation of theIFPA is a preponderance of the evidence.” Certain Underwriters at Lloyd’s of London v. Alesi,843 F. Supp. 2d 517, 530 (D.N.J. 2011).

The unchallenged facts in this case demonstrate that the Felipe Defendants knowingly made falserepresentations to 21st Century in order to obtain the Policy. In that regard, it is undisputed that

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the Felipe Defendants submitted an online application to 21st Century for a personal insurance policy in the name of Myriam Ledee,knowing that that policy procured would be used to cover the Van. In his deposition, Felipe Sanchez, Jr. admitted wrongdoing in procuringa personal policy in the name of Ledee, despite knowing that the Policy would be used for commercial purposes to insure the Van.

Because 21st Century has been prejudiced by the Felipe Defendants’ failure to defend this action, and no facts suggest that the FelipeDefendants would have a meritorious defense against the common law fraud claim. Accordingly, the Court finds that default judgmentagainst the Felipe Defendants as to liability for common law fraud is appropriate.

RESCISSION

Within the field of insurance, rescission has long been recognized as an available and necessary remedy tocombat fraudulent behavior by an insured.

Here, the Felipe Defendants made material and fraudulent misrepresentations by applying for a personal policyof insurance using the identity of Ledee. By failing to disclose their true identities, the Felipe Defendantsdeprived 21st Century of the opportunity to examine the driving histories and other relevant records of theFelipe Defendants. Under New Jersey law, the Court found that 21st Century is entitled to rescind the Policyas it pertains to the Felipe Defendants, precluding the Felipe Defendants from seeking any coverage asinsureds.

21ST CENTURY’S COVERAGE OBLIGATIONS FOR THE PASSENGERS

Notwithstanding the Court’s entry of judgment against the Felipe Defendants, and declaration that the Policy is void ab initio, the Courtmust determine whether 21st Century has any coverage obligations to the Passengers, who were innocent third-party victims in theaccident. In that regard, as discussed in greater detail below, it is well-established under New Jersey law that innocent third-party victimsof automobile accidents can, under certain circumstances, recover benefits under a policy that is declared void ab initio on the basis offraud by the named insured.

By 1985, New Jersey was confronted with a growing number of cases where New Jersey residentswere injured in accidents caused by out-of-state drivers whose insurance coverage was less than NewJersey’s statutory requirements. The New Jersey Legislature enacted N.J.S.A. 17:28-1.4, commonlyreferred to as the “deemer statute,” as part of the state’s no fault insurance plan. If the Van qualifiesas an “automobile,” New Jersey’s policy of compensating innocent third-party victims of automobileaccidents would require 21st Century to provide the Passengers with the minimum statutoryinsurance requirements set forth in the deemer statute.

The deemer statute provides, in pertinent part, that automobile insurers, such as 21st Century, whoissue policies outside of New Jersey, but are authorized to issue automobile insurance policies within the state, “shall include in eachpolicy coverage to satisfy at least the liability insurance requirements of [the No Fault Act] . . . , whenever the automobile . . . insuredunder the policy is used or operated in this State.” N.J.S.A. 17:28-1.4. The deemer statute incorporates the following definition of“automobile,” requires it to be a “private passenger automobile of a private passenger or station wagon type that is owned or hired and isneither used as a public or livery conveyance…”

Because the Van was used as a public or livery conveyance, and customarily used in the occupation, profession or business of the insured,the Court found that the Van does not constitute an “automobile,” regardless of whether it falls under the first or second vehicleclassification set forth in N.J.S.A. 39:6A-2.

At time of the accident, Santana was employed as a driver for Felipe Express, and the Van was customarilyused as a transportation vehicle for Felipe Express. Because the Van was customarily used in the occupation,business, or profession of Santana, it does not qualify as an automobile under the deemer statute. Because thedeemer statute only applies policies covering “automobiles,” the Court’s finding that the Van is not anautomobile is fatal to the Passengers’ attempt to seek coverage under the deemer statute.

The Court concluded that it could not extend the deemer statute and to cover the innocent Passengers and thatthey are not entitled to coverage despite their status as innocent third-party victims of the accident, because the

deemer statute is not triggered where the vehicle in question is not an “automobile.”

ZIFL OPINION

Although it is sad that the innocent passengers are unable to collect from 21st Century Insurance to compel the insurer to pay when it wasthe victim of fraud would have been unconscionable. The owners and operators of the vehicle will be held responsible and required to useits assets to pay for the injuries suffered by the innocent victims of the accident.

E-Books from Barry ZalmaHeads I Win, Tails You Lose - 2017This E-book started as a collection of columns insurance consultant, insurance lawyer Barry Zalma wrote and publishedin the magazines “Insurance Journal,” “Insurance Week,” and “The John Cooke Insurance Fraud Report.” It nowcontains 87 fictional stories on how insurance fraud is perpetrated by changing the names and places of the incident toprotect the guilty.

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Since the last edition I have added more stories that were published in my twice monthly newsletter, Zalma’s Insurance Fraud Letter whichis available free to anyone who clicks the link and a brief analysis of the California Special Investigation Unit Regulations. In addition thee-book has been totally rewritten correcting typographical and syntax errors.

The title, “Heads I Win, Tails You Lose” is meant to describe insurance fraud as it works in the United States. Whenever a person succeedsin perpetrating an insurance fraud everyone who buys insurance is the loser. If the fraud succeeds the insurer must charge more premium tocover the expense of defending the fraud and payment of funds to the fraud perpetrator. If the fraud fails the insurer must still charge morepremium to cover the expense of defending the fraud.

Everyone, except the lawyers and fraud perpetrators, lose.

After you make a payment through PayPal, please wait for the article to upload to your machine. If you have a problem with the purchaseplease write to me at [email protected].

DOJ Announces Hurricane Fraud Units In EffectThe National Center for Disaster Fraud (NCDF) along with U.S. Attorneys’ Offices in the District of Puerto Rico, Southern District ofFlorida, Middle District of Florida and Northern District of Florida have formed task forcescomprised of local, state and federal agencies in their respective areas to combat Hurricane Irmarelated illegal activity.

The NCDF and U.S. Attorneys in those districts are urging residents and businesses to immediatelyreport suspected fraudulent activity relating to recovery and cleanup operations, fake charitiesclaiming to be providing relief for victims, individuals submitting false claims for disaster relief andany other disaster fraud related activity.

The U.S. Department of Justice established the National Center for Disaster Fraud to investigate,prosecute, and deter fraud in the wake of Hurricane Katrina, when billions of dollars in federaldisaster relief poured into the Gulf Coast region. Its mission has expanded to include suspected fraudfrom any natural or manmade disaster. More than 30 federal, state, and local agencies participate in the NCDF, which allows the center toact as a centralized clearinghouse of information related to disaster relief fraud, according to a statement from the Department of Justice.

“While compassion, assistance, and solidarity are generally prevalent in the aftermath of natural disasters, unscrupulous individuals andorganizations also use these tragic events to take advantage of those in need,” the statement said.

NCDF noted that in the wake of Hurricanes Harvey and Irma, it had already received more than 400 complaints.

Examples of illegal activity being reported to the NCDF and law enforcement include:

• Impersonation of federal law enforcement officials;

• Identity theft;

• Fraudulent submission of claims to insurance companies and the federal government;

• Fraudulent activity related to solicitations for donations and charitable giving;

• Fraudulent activity related to individuals and organizations promising high investment returns from profits from recovery andcleanup efforts;

• Price gouging;

• Theft, looting, and other violent crimeS,

Unfortunately, criminals can exploit disasters, such as Hurricanes Harvey and Irma, for their own gain by sending fraudulentcommunications through email or social media and by creating phony websites designed to solicit contributions.Once the NCDF receives a complaint, it routes the complaints to the appropriate federal, state, or local lawenforcement agency in the appropriate jurisdiction. In the process, we are able to de-conflict and identify trends,national schemes, and offenders operating in multi-jurisdictions. The Justice Department will aggressively pursuethose who commit disaster fraud.

Acting U.S. Attorney W. Stephen Muldrow for the Middle District of Florida and U.S. Attorney Christopher P.Canova for the Northern District of Florida urged anyone suspecting fraud to call the NCDF Hotline toll free at(866) 720-5721. The telephone line is staffed by a live operator 24 hours a day, 7 days a week. Information canalso be faxed to the Center at (225) 334-4707, or emailed to [email protected] (link sends e-mail).

The Zalma Insurance Claims LibraryThe full Zalma Insurance Claims Library is available at

Insurance Claims: A Comprehensive Guide

Zalma's Insurance Fraud Letter -- Page 7 of 20

Heinlein

Insurance Law

Mold Claims Coverage Guide;

Construction Defects Coverage Guide

Wisdom“The useless men are those who never change with the years.” – J.M. Barrie

“A general dissolution of principles and manners will more surely overthrow the liberties of America than thewhole force of the common enemy.” —Samuel Adams

“I do not feel obliged to believe that the same God who has endowed us with sense, reason, and intellect hasintended us to forgo their use.” — Galileo Galilei

“Those who expect to reap the blessings of freedom, must, like men, undergo the fatigues of supporting it.” —Thomas Paine

“Optimism is the faith that leads to achievement.” – Helen Keller

“Nothing is less productive than to make more efficient what should not be done at all.” — Peter Drucker

“Violence, naked force, has settled more issues in history than has any other factor, andthe contrary opinion is wishful thinking at its worst. Nations and peoples who forget this basic truth have always paidfor it with their lives and freedoms.” — Robert A. Heinlein

“I am persuaded that a firm union is as necessary to perpetuate our liberties as it is to make us respectable.” —Alexander Hamilton

“t is a thing of no great difficulty to raise objections against another man’s oration -- nay, it is a very easy matter --but to produce a better in its place is a work extremely troublesome.” – Plutarch

“The image is one thing and the human being is another. ... It’s very hard to live up to an image.” – Elvis Presley

“Guard against the impostures of pretended patriotism.” — George Washington

Barry ZalmaBarry Zalma is the principal of Barry Zalma, Inc. He is available for consultation on any and all insurance issues facedby you or your clients.

Barry Zalma founded the firm to help resolve every insurance claim problem faced by you or your clients. Hisexperience and skill as a consultant can make the difference before a jury or other trier of fact. For more than 45 yearsas a claims person and insurance coverage attorney, Barry Zalma has represented insurers, advised insurers on claimshandling, interpreted coverages and testified as an insurance coverage, insurance bad faith, insurance claims handlingand insurance fraud expert on behalf of insurers and policy holders’ suing insurers.

Mr. Zalma has been rated “AV Preeminent” and is an internationally recognized expert on insurance, insurance claimshandling, insurance coverage, insurance fraud, and insurance bad faith. Barry Zalma will promptly review your file materials and adviseyou about the viability of your decision to sue or your defenses. He can help you narrow the scope of discovery.

Consultation with Mr. Zalma can save you or your client thousands of dollars in the defense or prosecutionof an insurance dispute. Mr. Zalma will assist you in the effort to find a solution to an insurance claimsdispute that is fair, intelligent, beneficial and economical.

He is available to provide expert advice to individuals and their counsel.

Mr. Zalma’s rates are all inclusive. Mr. Zalma’s hourly fee takes account of all incidentals from telephonecalls and postage.

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Good News From the

* Homeowners timed their insurance arson for when the fire department was sidelined at a memorialservice for 2 comrades who’d died fighting a blaze just a few days earlier. Luckily a neighboring firedepartment was on call and doused the flames engulfing wood structure in Toledo, Ohio. Reinaldo andMaylin Torna even sued the insurer after the fire. They were caught dead to rights after a tipster outed theirscheme. Investigators also found multiple points of origin. The Tornas begged for community control. Theyhave 2 children, including one with mental-health issues. Plus they had no priors. The judge had littlesympathy, given that they’d undermined firefighters, and jeopardized people’s lives and neighboring homes.The judge handed the Tornas 6 months of prison to go with 5 years of community control.

* Andrea Ball Rudd stole $5.4 million of money her small-business clients handed over to pay for comp premiums. The Knoxville,Tenn.-area woman ran a purported HR services firm called HR Comp, with a slew of subsidiaries. Rudd also stole $10.4 million that clientsgave her to pay payroll taxes. The loot subsidized a lavish lifestyle. The federal probe began when a worker was killed on the job. Hisemployer discovered Rudd had faked comp paperwork, leaving the firm and worker uncovered. Rudd received 8 years in federal prison,and must repay more than $15 million. She learned her criminal tactics as an employee of mentor Zebbie Joe Usher. He ran a similar firmcalled Service Provider Group, also in Tennessee. Usher was handed up to 5 years in federal prison for a $30-million tax fraud scheme.That firm’s CFO killed himself in his backyard, and the COO shot himself in a cemetery.

* Marie Neba screwed up and expected jail — though hardly this much. The home-health agency owner in the Houston area robbedMedicare of $13 million and got caught. Her jail term has experts scratching their heads. The judge handed Neva 75years in prison. This relatively routine case breaks the previous healthcare record by 25 years. Neva also is dying. Shehas terminal breast cancer. The disease has spread to her bones and lungs. And Neva has twin 7-year-old kids. Herremarkable sentence comes amid a stern federal crackdown on health fraud. “I’m not a heartless person,” judge MelindaHarmon said before announcing the sentence. Neva’s appealing. The prior longest fraud sentence came in 2011.Lawrence Duran owned a Miami-area mental healthcare firm. He received 50 years for a $205-million Medicare schemethat defrauded vulnerable patients with dementia and addiction. Dr. Farid Fata got 45 years for inflicting massive dosesof disfiguring chemo on healthy patients in the Detroit area. Federal prosecutors called him the “most egregiousfraudster in the history of this country.”

* Valentina Kovalienko was a large cog in a network of Brooklyn, N.Y. clinics that stole more than $55 million fromMedicare and Medicaid. She paid patients cash kickbacks to undergo useless physical and occupational therapy, and tests that weren’tperformed by licensed professionals. Kovalienko also bribed therapists to falsify patient charts and billing records. Kovalienko launderedthe insurance payouts through an elaborate network of sham third-party vendors. The bills purportedly were for “consulting,” “advertising”and “computer support.” Kovalienko’s only future consulting will be with jail handlers. She was handed 7 years in federal prison and mustrepay $29.3 million.

* Psychologist Rodney Hesson could use some counseling of his own. The Louisiana man billed Medicare formore than $13 million of bogus counseling claims, many of which defied logic. Hesson billed in Louisiana,Mississippi, Florida and Alabama. Some billings were so excessive that he needed to work 30 hours a day for 365days a year to finish the claimed counseling cases. He also did counseling at senior centers. Yet some seniors hadsevere dementia. Some couldn’t speak. Some were completely unresponsive, yet supposedly took psychologicaltests. Hesson received 15 years in federal prison.

* Speech therapist Joseph Penaranda Tan’s $400,000 con was silenced. He mostly worked with kids, and had contracts with schooldistricts in the Morristown, Tenn. area. He often billed insurers for individual therapy actually given in a group setting. That hiked hisbillings. Tan also charged for speech therapy for Spanish-speaking students whose only impediment was that they didn’t speak English.Non-credentialed therapists in his practice used the provider numbers of a licensed therapist more than 7,000 times. An employeequestioned his billing practices. Tan responded with a simple reason for using the wrong code: make more money. Tan has pleaded guiltyand prosecutors recommend 18 months in federal prison.

* The former director of a Memphis chiro clinic ratted out the operation allegedly for illegally telemarketing crash victims fortreatment under the guise of being a quasi-government agency. Here’s what Shon Knott alleges to reporters: Reps fromPremium Medical Services pulled names of crash victims from police reports then pitched treatment under the guise ofthe fake Accident Victims Advocacy Bureau. Many victims told the cold-callers they weren’t hurt, yet still received aPIN and followup call to schedule an appointment. The sales pitches violated Tennessee medical ethics rules. Medicalpersonnel and their reps are prohibited from soliciting auto accident victims within 30 days of crashes. The clinic had

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only rudimentary equipment such as yoga balls and stationary bikes. The patients all were labeled not-at-fault victims, and the at-faultdriver’s insurer was billed. The Tennessee Health Department and NICB are investigating.

* An angry employee lied he was clonked by a forklift so he could score a bogus workers-comp claim.Randal Brown McKay berated a forklift driver at an industrial plant in the Santa Ana, Calif. area. The guydidn’t open up plastic strips at a door to let more air in. McKay jumped in front of the forklift, daring theemployee to hit him. The machine stopped short, yet McKay claimed the guy drove the forklift into him,striking him with a pallet. McKay reported the incident to police and filed a comp claim. He repeated theattack story under oath. The plant’s video confirmed McKay wasn’t hurt. Turns out McKay did the roughingup. He struck the employee in the head, causing 8 stitches and blurred vision. McKay pleaded guilty to assaultand making a false insurance claim. He received 6 months in prison.

* Sandy Vargas said someone heavily vandalized her 2002 Chevy Tahoe, leaving scratches throughout the truck. Repairs cost morethan $6,000, yet the West Sacramento woman gave 21st Century Insurance only a vague location and multiple stories. The insurer deniedher claim, and Vargas sued. The court squelched her action, then the auto investigators for Yolo County went after Vargas. She couldn’tprovide a specific location, parking lot or intersection where her truck was vandalized. Later, Vargas said she parked her truck in theparking lot of Mercado Loco in West Sacramento, at 8 a.m. and entered the store. She left the store about 30 minutes later and noticed hertruck was vandalized, she said. Yet Vargas never contacted the West Sacramento Police Department to file a damage report. She alsohadn’t made truck payments for 6 months, and was trying to sell the vehicle. Vargas pleaded no contest, received 6 months of probation

and must repay $1,042.

* A plea deal allowed the co-owner of a barbecue joint to evade insurance charges after the financiallystrapped place burned down. David Galbraith owned Blue Smoke BBQ in Alexandria, Minn. He allegedly hiredhis manager Derrick Bradley to torch the eatery for $266,000 of insurance loot. The manager stepped forward andadmitted all. Turns out that Galbraith owed employees, vendors and the state money. Bradley came clean and wentto law enforcement after the fire. Investigators wired Bradley. He was instructed to tell Galbraith he was concernedabout people knowing about the arson, and ask Galbraith who else knew about it. Galbraith identified theemployees who knew of the payment and arson. He pled guilty to a single charge. The arson and insurance-fraudcharges were dropped in return. Galbraith will be sentenced Nov. 14.

* Richard A. Mariani was a transportation security officer at Barnstable Municipal Airport in Mass. A work injury imposed seriouslimits on physical activities, he claimed. Docs agreed, and Mariani left work with federal comp benefits. He was discovered doing lawnirrigation services for clients, who paid him in cash. Mariani also lied on a federal form that comp benefits were his only income source.He fraudulently received more than $38,000. Mariani pleaded guilty and will receive up to a year in federal prison when sentenced.

* A crooked doc falsely billed Medicare more than $50 million for worthless home healthcare. The feds repaid the favor by handingDr. Noble Ezukanma nearly 17 years in prison. The Fort Worth, Tex. man billed Medicare at an “alarming rate,” officials said.Home-health firms he co-owned generally billed only for the most-comprehensive physician exams. Most visits took only 15-20 minutes,yet the firm billed Medicare for visits of 90 minutes or more. More than 97 percent of his Medicare patients received home healthcare,even if it wasn’t medically necessary.

Health Insurance Fraud Convictions

ANMED Health agrees to pay $7 million

AnMed Health, a South Carolina hospital based in Anderson, South Carolina, has agreed to pay over $7 million toresolve allegations that it violated the False Claims Act by submitting false Medicare claims. The settlementannounced today resolves allegations that AnMed Health knowingly disregarded the statutory conditions forsubmitting claims to the Medicare program for a variety of services, including radiation oncology services,emergency department services, and clinic services.

Specifically, the United States alleged that AnMed Health billed for radiation oncology services for Medicare patientswhen a qualified practitioner was not immediately available to provide assistance and direction throughout theradiation procedure, as required by Medicare regulations. The settlement also resolves allegations that AnMedHealth systematically billed a minor care clinic as if it was an Emergency Department and billed EmergencyDepartment services as if they were provided by a physician when, in fact, the services were rendered by mid-levelproviders. Each of these billing practices resulted in higher reimbursements to AnMed Health.

The allegations settled arose from a lawsuit filed in the Northern District of Georgia by a whistleblower formerly employed by AnMedHealth, Linda Jainniney, under the whistleblower provisions of the False Claims Act. Under the Act, private citizens can bring suit onbehalf of the government for false claims and share in any recovery. The lawsuit is captioned United States ex rel. Jainniney v. AnmedHealth, et al., 1:12-cv-2941 (N.D. Ga.). Under the provisions for whistleblowers under the False Claims Act, Ms. Jainniney will receive$1,202,500 of the United States’ False Claims Act recovery.

Pharmaceutical Wholesaler to Pay $260 Million for Illegally Distributing Millions of Misbranded OncologyDrug Products

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AmerisourceBergen Specialty Group (ABSG), a wholly-owned subsidiary of AmerisourceBergenCorporation (NYSE: ABC),On September 27, 2017, pled guilty to illegally distributing misbrandeddrugs. at the federal courthouse in Brooklyn, New York. Amerisource is one of the nation’s largestwholesale drug companies and number 11 on the Fortune 500 list.

ABSG agreed to pay a total of $260 million to resolve criminal liability for its distribution of oncologysupportive-care drugs from a facility that was not registered with the Food and Drug Administration(FDA). The guilty plea and sentencing took place before United States District Judge Nina Gershon.

As set forth in court records, between 2001 and 2014, two of ABSG’s Alabama-based subsidiaries,Medical Initiatives Inc. (MII) and Oncology Supply Company (OSC), prepared millions of syringes that had been pre-filled with oncologysupportive care drugs — specifically, Aloxi®, Anzemet®, generic versions of granisetron injection, Kytril®, Neupogen® and Procrit®. Those syringes were shipped to oncology centers, medical practices and physicians for administration to immunocompromised cancerpatients undergoing chemotherapy treatment in all 50 states, including to approximately 37 healthcare providers located in the EasternDistrict of New York.

To prepare pre-filled syringes (PFS), MII removed FDA-approved drug products from their original glass vials and repackaged them intoplastic syringes through a process that allowed MII to access and sell excess drug product in the vials, known as “overfill,” that MII wasable to extract from the vials. As alleged in the Information, however, MII prepared PFS in an unclean, unsterile environment. Accordingly, MII’s process for creating PFS resulted in some PFS that contained particles or foreign matter, which MII employeesidentified and termed “floaters.” PFS were also at times not of the quality or purity that MII and OSC represented them to be to theircustomers.

MII’s business model was to combine the contents of multiple vials in a process known as “pooling.” However, as set forth in theInformation, many of the vials used by MII to prepare PFS were designated by the drug manufacturer as “single use” vials, meaning thatthe manufacturer could not guarantee the sterility of the drug product if the vials were breached. However, in the pooling process, MII’stechnicians frequently breached drug vials multiple times, thereby increasing the risk of contamination.

In order to avoid the FDA’s regulatory oversight, ABSG did not register MII as a re-packager or manufacturerwith the FDA as required by the Federal Food, Drug and Cosmetic Act. Instead, ABSG inaccurately portrayedMII to its customers and to state agencies as a state-regulated pharmacy in the business of dispensing drugspursuant valid prescriptions and claimed that MII was otherwise in compliance with state pharmacy laws. Byholding MII out as a pharmacy, ABSG unlawfully exploited an exemption to the FDA registration requirementthat is reserved for legitimate pharmacies, not for manufacturers or re-packagers.

In connection with the guilty plea, ABSG filed a Statement of Facts setting forth those facts which it isadmitting.

As part of its guilty plea, ABSG has agreed to pay a $208 million criminal fine, plus $52 million in criminalforfeiture, for a total financial penalty of $260 million. In addition, ABSG has entered into an agreement withthe Office and the Department of Justice’s Consumer Protection Branch to maintain a compliance and ethics program designed to increaseaccountability of individuals and corporate board members, to increase transparency, and to strengthen ABSG’s compliance with theFDCA. The compliance and ethics program requires corporate board members to review annually the effectiveness of the company’scompliance program and for ABSG to maintain a hotline that will receive and process complaints about any improper practices.

Podiatrist Pays $35,000 to Settle Allegations under the False Claims Act

Edward Tarka, a podiatrist with a practice in Norwich, Connecticut, has entered into a civil settlement with the government in which hewill pay $35,000 to resolve allegations that he violated the False Claims Act.

The allegations against Tarka involve fraudulent billing to Medicare for avulsion services, a surgical procedure to treat ingrown toenails. The procedure involves the surgical separation and removal of all or part of a toenail from the tip of the nail back to the base of the nail. The government alleges that Tarka submitted claims to Medicare for avulsion services under CTP Code 11730 that were not performed inaccordance with Medicare requirements. Specifically, the government alleges that Tarka “upcoded” ingrown toenail services, submitting

claims to Medicare for avulsion services when in fact he had provided only “routine foot care” servicesto his Medicare patients.

Routine foot care is typically not a payable service under relevant Medicare regulations, except inlimited circumstances for patients with certain systemic conditions or other significant medical issues.

To resolve his liability under the False Claims Act, Tarka will pay $35,000, in order to reimburse theMedicare program for conduct occurring between August 2008 and August 2012.

Under the False Claims Act, the government can recover up to three times its actual damages, pluspenalties of $10,957 to $21,916 for each false claim.

Adult Daycare Facility Agrees To $2.72 Million Settlement T

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Edison Adult Medical Daycare (Edison), its former owner, Dinesh Patel, and current owners, Daxa Patel and Satish Mehtani, haveagreed to pay the United States and the State of New Jersey $2.72 million to resolve allegations that Edison improperly billed and receivedpayments from Medicaid despite Dinesh Patel having been excluded from participating in Medicaid following his 2012 conviction foraccepting kickbacks.

On Sept. 19, 2012, Dinesh Patel pleaded guilty to accepting cash kickback payments from Orange Community MRI LLC in exchange forpatient referrals. He was later sentenced to three months in jail and two years of supervised release.

On March 17, 2012, Dinesh Patel was excluded by the State of New Jersey from participating in any capacity in the Medicaid program.Later, on Feb. 20, 2014, Dinesh Patel was excluded by the U.S. Department of Health and Human Servicesfrom participating in Medicare, Medicaid, and all federal health care programs for a period of five years. Fivedays after Dinesh Patel’s Medicaid exclusion in 2012, he transferred his 50 percent ownership interest inEdison to his wife, Daxa Patel.

The September 27, 2017 settlement resolves federal and state government allegations that from March 17,2012, through Aug. 4, 2015, Dinesh Patel violated his exclusion by not ceasing his involvement in the adultdaycare facility, and that Edison violated the False Claims Act by submitting claims to and receiving paymentsfrom Medicaid while Dinesh Patel directed, managed and supervised activities at Edison. The settlement alsoresolves allegations that owners Daxa Patel and Satish Mehtani had full knowledge that Dinesh Patel wasmanaging Edison while he was an excluded Medicaid provider.

Dinesh Patel, Daxa Patel, Satish Mehtani, and Edison have agreed to pay $2.72 million plus interest to be split equally between UnitedStates and State of New Jersey. Dinesh Patel has also agreed to another five-year exclusion precluding him from participating in all federalhealth care programs, including Medicaid and Medicare, until 2022.

Podiatrist Convicted Of 16-Month Scheme To Defraud Medicare And Other Health Care Benefit Programs

Podiatrist John J. Cauthon, 51, of Murfreesboro, Tenn., was convicted September 27, 2017 by a federal jury of four counts of health carefraud involving a 16-month scheme to defraud Medicare and other health care benefit programs. The convictions came after a two-weektrial before United States Chief District Judge Waverly D. Crenshaw, Jr. Cauthon was also acquitted of three counts of health care fraud.

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According to the Indictment and the evidence presented at trial, from May 2014 to August 2015, Cauthonexecuted a scheme to defraud Medicare, TennCare, and Blue Cross Blue Shield of Tennessee by submittingfalse and fraudulent claims for surgical procedures he did not perform. Cauthon traveled around to nursinghomes across Tennessee and up-coded routine foot care to nail avulsions, which is paid out a higher rate byMedicare. Cauthon’s former employees testified at trial that they witnessed him prescribe medicallyunnecessary ankle braces to bed-bound patients and witnessed him pocket Medicare funds after durablemedical equipment was returned or never picked up by patients.

Cauthon is scheduled to be sentenced on January 26, 2018. He faces up to 10 years in prison and a $250,000 fine for each count of healthcare fraud.

Aegerion Agrees to Plead Guilty; Will Pay More Than $35 Million

Aegerion Pharmaceuticals Inc., a Cambridge, Massachusetts-based subsidiary of Novelion Therapeutics Inc., has agreed to plead guiltyto charges relating to its prescription drug, Juxtapid, the Justice Department announced on September 22, 2017.

As charged in a criminal information Aegerion introduced Juxtapid into interstate commerce that was misbranded because, among otherthings, Aegerion failed to comply with a Risk Evaluation and Mitigation Strategy (REMS). The resolution also includes a deferredprosecution agreement relating to criminal liability under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Inaddition, Aegerion agreed to settle allegations that it caused false claims to be submitted to federal health care programs for Juxtapid. Aegerion agreed to pay more than $35 million to resolve criminal and civil liability arising from these matters. Aegerion has also agreed toenter into a civil consent decree of permanent injunction aimed at preventing future violations of the Federal Food, Drug, and Cosmetic Act(FDCA).

In a criminal information filed on Sept. 22 in the District of Massachusetts, the United States chargedthat, from December 2012 to December 2015, Aegerion introduced into interstate commerce Juxtapid, adrug that was misbranded under the FDCA. During this time period, Juxtapid was approved by theU.S. Food and Drug Administration (FDA) to treat patients with homozygous familialhypercholesterolemia (HoFH), a rare disorder, inherited from both parents, that prevents the removal ofLDL-C, often called the “bad” cholesterol, from the blood, causing abnormally high levels ofcirculating LDL-C. The Juxtapid label carried a black box warning that Juxtapid may cause livertoxicity, a serious side effect of using the drug, and the label also warned that Juxtapid may causegastrointestinal adverse reactions. FDA required a REMS, which is a risk management plan deemednecessary to ensure that a drug’s benefits outweigh its risks, as part of Juxtapid’s approval. The specific purpose of the Juxtapid REMSwas to educate prescribers about the risks of liver toxicity and to restrict access to Juxtapid only to those patients with a clinical orlaboratory diagnosis consistent with HoFH.

The information alleges that during the relevant time period, Aegerion failed to give health care providerscomplete and accurate information about HoFH and how to properly diagnose it, and that Aegerion also filed amisleading REMS assessment report. According to the information, Aegerion therefore failed to comply withthe required elements under the REMS to assure safe use of Juxtapid, in violation of the FDCA. Theinformation further alleges that Aegerion management and sales personnel distributed Juxtapid not only for thetreatment of HoFH, but also as a treatment for high cholesterol generally, without adequate directions for suchuse. Under the terms of a plea agreement, Aegerion has agreed to plead guilty to these charges and pay acriminal fine and forfeiture of $7.2 million.

In a deferred prosecution agreement to resolve a felony charge that Aegerion conspired to violate HIPAA, 42U.S.C. §§ 1320d-6(a) and 1320-6(b)(3), Aegerion admitted that it conspired to obtain patients’ personally

identifiable health information, without patient authorization, for commercial gain. Under the terms of the deferred prosecution agreement,Aegerion will implement enhanced compliance provisions, including periodic certifications to the government concerning itsimplementation of those provisions.

Under the civil false claims settlement, Aegerion will pay $28.8 million over three years to resolve federal and state civil liability forcausing false claims for Juxtapid to be submitted to government health care programs (Medicare, Medicaid, and TRICARE) arising fromits promotion of Juxtapid for patients without a diagnosis of, or consistent with, HoFH; false and misleading statements to doctors that theuse of Juxtapid was appropriate in patients with symptoms including high cholesterol, irrespective of whether such patients had a diagnosisof HoFH and despite counter-indications to a diagnosis of HoFH; and alteration or falsification of statements of medical necessity and priorauthorizations that were submitted to federal health care programs. The government further alleged thatAegerion defrayed patients’ copayment obligations for Juxtapid, in violation of the Anti-Kickback Statute(AKS), by funneling funds through Patient Services Inc. (PSI), an entity that claimed to be a non-profit patientassistance organization. The federal share of the $28.8 million civil false claims settlement is $26.1 millionand the state portion is $2.7 million.

As part of the resolution, Aegerion has agreed to enter into a separate civil consent decree to resolve civilliability under the FDCA in connection with its failure to comply with the requirements of the Juxtapid REMSprogram and its distribution of Juxtapid with labeling that lacked adequate directions for all of Juxtapid’sintended uses. Aegerion also entered into a Corporate Integrity Agreement (CIA) with the HHS-OIG. The

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five-year CIA requires, among other things, that Aegerion implement measures designed to ensure that itspromotional activities and any arrangements and interactions with third-party patient assistance programs complywith the law. In addition, the CIA requires reviews by an independent review organization andcompliance-related certifications from company executives and Board members.

The civil false claims settlement resolves a lawsuit filed by Michele Clarke, Tricia Mullins, and Kristi WingerSzudlo, former employees of Aegerion, under the qui tam or whistleblower, provisions of the False Claims Act,which permit private individuals, known as relators, to sue on behalf of the government for false claims and toshare in any recovery. The qui tam suit was filed in the District of Massachusetts and is captioned United Statesex rel. Clarke, et al. v. Aegerion Pharmaceuticals, Inc., et al., No. 13-CV-11785 (D. Mass.). Relators will receive$4.7 million from the federal proceeds of the civil false claims settlement.

ZIFL only wonders why no one is going to jail. Money is nice but true punishment is needed.

Clinical Psychologist Sentenced to 25 Years in Prison for Role in $550 Million Social Security Fraud Scheme

Alfred Bradley Adkins, 46, of Pikeville, Kentucky, was sentenced by U.S. District Judge Danny C. Reeves of the Eastern District ofKentucky, to serve 25 Years in Prison and also ordered Adkins to pay restitution of over $93 million to the SSA and HHS. Adkins wasfound guilty following a six-day trial in June 2017 of one count of conspiracy to commit mail fraud and wire fraud, one count of mailfraud, one count of wire fraud and one count of making false statements.

Adkins, a former Kentucky clinical psychologist was sentenced September 22, 2017 for his role in a scheme to fraudulently obtain morethan $550 million in federal disability payments from the Social Security Administration (SSA) for thousands of claimants.

According to trial evidence, beginning in 2004, David Black Daugherty, an SSA administrative law judge assigned to the SSA Huntington,West Virginia, hearing office, sought out pending disability cases in which Kentucky attorney Eric Christopher Conn representedclaimants and often reassigned those cases to himself. Daugherty then contacted Conn and identified the cases he intended to decide thefollowing month and further solicited Conn to provide either physical or mental medical documentation supporting disabilitydeterminations, whether or not the claimants were actually disabled. When mental medical documentation was requested, Conn solicitedAdkins to sign medical evaluation forms that Conn had previously prepared. Without first reviewing these forms, Adkins signed them;Conn subsequently forwarded the forms to the SSA, primarily to Daugherty, in support of disability determinations. Conn, in turn, paidDaugherty more than $609,000 for granting benefits in his cases, and almost $200,000 to Adkins for signing the fraudulent forms. For hispart, Conn received more than $7 million in related attorney’s fees.

As a result of the scheme, Adkins, Conn, Daugherty and others obligated the SSA topay more than $550 million in lifetime benefits to claimants based upon casesDaugherty approved for which he received payment from Conn.

Adkins was indicted last year, along with Conn and Daugherty. The defendants werecharged with conspiracy, fraud, false statements, money laundering and other relatedoffenses in connection with the scheme. Daugherty pleaded guilty in May 2017 to atwo-count information charging him with receiving illegal gratuities, and wassentenced on August 25, to 4 years in prison.

Conn pleaded guilty on March 24, to a two-count information charging him with theft of government money and paying illegal gratuities,and was sentenced on July 14 to 12 years in prison. Conn subsequently absconded from electronic monitoring on June 2, and is considereda fugitive. Conn remains charged under the original indictment.

The FBI is offering a reward of up to $20,000 for information leading to the arrest of Eric Christopher Conn. Anyone with informationrelating to Conn’s whereabouts should contact their local FBI office or the nearest American Embassy or Consulate.

Dental Office Manager Sentenced to Prison for Defrauding Insurance Companies

Elena Ilizarov, 45, of Stamford, was sentenced September 22, 2017 by U.S. District Judge Victor A. Bolden in Bridgeport to 12 monthsand one day of imprisonment, followed by three years of supervised release, for using an identity theft victim’s personal identifyinginformation to submit fraudulent bills to private insurance companies offering dental insurance.

According to court documents and statements made in court, Ilizarov served as the office manager for Advanced Dentistry, a dentalpractice located in Stamford. Between 2005 and 2016, Ilizarov billed 37 private dental insurance companies for services allegedly

performed by an identity theft victim for patients of Advanced Dentistry, when the victim did not in factperform those services. The identity theft victim was a dentist who had been affiliated with AdvancedDentistry for a short period of time and retired fully from dentistry in 2011. In total, Ilizarov earned more than$1.2 million by billing in the name of the retired dentist.

Between 2011 and 2015, approximately $581,729 was paid by private insurance companies to AdvancedDentistry for services allegedly provided by the retired dentist. As a result, the insurance companies issued1099 forms to the Internal Revenue Service pertaining to the retired dentist. In 2015 and 2016, ILIZAROV

renewed the retired dentist’s Connecticut dental license and controlled substance registrations, paying for the renewals with her personalcredit card. She also applied for, and received, liability insurance in the name of the retired dentist for several years.

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Ilizarov was arrested on a federal criminal complaint on June 21, 2016. On March 13, 2017, she pleaded guilty to one count of wire fraud.

Guilty of Healthcare Fraud - 80 Months in Prison

Lisa Crinel age 52; of New Orleans, and PCAH, Inc. a/k/a Priority Care at Home, Inc. D/b/a Abide Home Care Services Inc.(“ABIDE”), were sentenced today for their roles in approximately $30,052,295 in Medicare fraud.

U.S. District Judge Susie Morgan sentenced Crinel to 80 months imprisonment, followed by three years ofsupervised release, and restitution to Medicare in the amount of $16,088,222. The corporation Crinel owned,PCAH, Inc. A/k/a Priority Care at Home, INC. d/b/a Abide Home Care Services Inc., was sentencedSeptember 21, 2017 to five years of probation and restitution to Medicare in the amount of $16,088,222.

On March 12, 2015, Crinel and Abide were indicted along with 19 other defendants in a 26-count indictment.

On October 2, 2015, Crinel pled guilty to one count of conspiracy to commit healthcare fraud and one count ofconspiracy to pay and receive illegal kickbacks. That same day, Abide pled guilty to one count of conspiracyto commit health care fraud.

According to court documents, Crinel was the owner and operator of Abide, a business that provided homehealth care services to homebound individuals who were primarily Medicare beneficiaries. As the owner and Chief Operating Officer ofAbide, Crinel took a “100 percent hands on approach” that extended to “almost every aspect of the operation” of the business. Home healthexperts trained Crinel and her staff on who qualified for home health and how home health services should be documented. Evidenceseized at the search of Abide’s office established that Crinel maintained Abide’s Medicare Provider Number and routinely certified onbehalf of Abide that she would not knowingly present or cause to be presented false or fraudulent claims for payment by Medicare.Nevertheless, Crinel instructed her staff not to discharge patients, even those who did not require home health services. Abide, underCrinel’s direction, also routinely falsified diagnoses codes and medical records to cause inflated reimbursements from Medicare. Crinel andAbide created an atmosphere where nurses and other healthcare professionals would compromise their medical and ethical judgment inorder to defraud Medicare. Court documents also show that Crinel and Abide entered into sham employment contracts and medical directorcontracts with doctors and others to cover up the illegal kickback relationship between Crinel, Abide, and those doctors and otherindividuals. Four physicians have since been convicted for their roles in the conspiracies and are awaiting sentence.

Health Care Business Owners Plead Guilty To Fraud

THURLEE BELFREY, 52, ROYLEE BELFREY, 52, and LANORE BELFREY, 42, pleaded guilty on September 14, 2017, beforeSenior U.S. District Judge Ann D. Montgomery in Minneapolis, Minn.

According to the defendants’ guilty pleas and the indictment in the case, brothers THURLEE andROYLEE BELFREY ran multiple health care businesses that received funds from the Medicaid andMedicare programs funded by the federal government and the State of Minnesota. In 2003, following aninvestigation by the Minnesota Attorney General’s Office into Royal Health Care, a business they startedtogether in the 1990s, THURLEE BELFREY was convicted of felony theft by false representation. Basedon his conviction, in 2004 the Minnesota Department of Human Services (DHS) and the United StatesDepartment of Health and Human Services (DHHS) excluded THURLEE BELFREY indefinitely fromparticipating in state and federal health care programs, with no right to seek reinstatement for up to 20years.

Despite this, and as he admitted in his guilty plea, THURLEE BELFREY conspired with his wife LANORE BELFREY to incorporate anew health care company, Model Health Care (Model), to continue the business operations and conceal THURLEE BELFREY’Sinvolvement therein. To do this, and part of the scheme, LANORE BELFREY was named the owner of Model and intentionally failed todisclose THURLEE BELFREY’S involvement in managing the business. Despite being excluded, THURLEE BELFREY continued tomanage Model. Government payment records show Model received more than $10,000,000 from Medicaid that would not have been paidbut for the fraudulent misrepresentations made about THURLEE BELFREY’S lack of involvement in the businesses. According to theinvestigation, THURLEE and LANORE BELFREY received millions of dollars from Model during the scheme.

While THURLEE BELFREY ran Model, ROYLEE BELFREY operated several health care businesses as well. According to thedefendants’ guilty pleas, between 2007 and 2013, THURLEE and ROYLEE BELFREY deducted and collected money from theiremployees’ wages, ostensibly for the payment of federal payroll taxes and Federal Insurance Contribution Act (FICA) taxes. However,they intentionally failed to pay the withheld taxes over to the IRS over the course of many years and, instead, used the money for otherpurposes, including attempts to develop a reality show based on their lives, high-end housing, a Caribbean cruise, luxury retail purchases,and thousands of dollars in cash withdrawals. In total, THURLEE and ROYLEE BELFREY admitted deducting and unlawfully using fortheir own benefit more than $3,960,000 in withheld taxes between 2007 and 2014.

Defendant Admits Billing D.C. Medicaid for Supplies That Were Not Provided

Emeka H. Chijioke, 40, formerly of Atlanta, Ga., and Nigeria, pled guilty September 19, 2017 to a federal charge of health care fraudstemming from a scheme in which he defrauded the District of Columbia’s Medicaid program out of more than $500,000.

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Chijioke pled guilty in the U.S. District Court for the District of Columbia. The charge carries a statutory maximum of 10 years in prisonand potential financial penalties. Under federal sentencing guidelines, Chijioke faces a likely rangeof 24 to 30 months in prison and a fineof up to $95,000. The plea agreement calls for Chijioke to pay $552,343 in restitution to the D.C.Medicaid program and an identical amount in a forfeiture money judgment. The Honorable SeniorJudge Paul L. Friedman scheduled sentencing for Dec. 13, 2017.

Chijioke was arrested in December 2016 in Germany and extradited to the United States in April2017 to face charges in an indictment returned in the District of Columbia.

According to a statement of offense submitted to the Court, Chijioke was the majority owner,registered agent, and chief executive officer of Mead Medical Group, LLC, a durable medicalequipment company organized in Maryland. Mead Medical provided medical equipment supplies,including incontinence supplies and garments, to District of Columbia Medicaid recipients.

Beginning in 2007 and continuing through 2012, Chijioke engaged in a scheme to defraud D.C. Medicaid by billing for incontinencesupplies that were not provided, as detailed in the statement of offense. Chijioke instructed his office staff to complete doctor prescriptionscalling for beneficiaries to receive the maximum amount of incontinence supplies allowed by D.C. Medicaid. At the same time, he had hisoffice staff contact the Medicaid recipients to determine from them the actual amount of incontinence supplies they needed, and to providethem with those supplies. Chijioke hired a billing company to submit claims to the Medicaid contractor as if the maximum amount ofsupplies were provided to the recipients rather than the actual amount supplied. By arranging for the maximum amount of incontinencesupplies to be billed, rather than the amount actually provided, Chijioke obtained approximately $580,000 that he was not entitled toreceive from Medicaid.

During the investigation, $28,600 in funds generated through the scheme was administratively forfeited.

Sentenced to 84 Months for Role in $55 Million Health Care Fraud Scheme

Valentina Kovalienko, 47, of Brooklyn, and the owner of Prime Care on the Bay LLC and Bensonhurst Mega Medical Care P.C., wassentenced by U.S. District Judge Roslynn R. Mauskopf of the Eastern District of New York, who also ordered Kovalienko to forfeit$29,336,497 on September 15, 2017. Kovalienko pleaded guilty in October 2015 to one count of conspiracy to commit health care fraudand one count of conspiracy to commit money laundering.

As part of her guilty plea, Kovalienko acknowledged that her co-conspirators paid cash kickbacks to patients to induce them to attend hertwo clinics. Kovalienko also admitted that she submitted false and fraudulent claims to Medicare and Medicaid for services that wereinduced by prohibited kickback payments to patients or that were unlawfully rendered by unlicensed staff. Kovalienko also wrote checksfrom the clinics’ bank accounts to third-party companies, which purported to provide services to the clinics, but which in fact were notproviding services, and the payments were instead used to generate the cash needed to pay the illegal kickbacks to patients, she admitted.

Twenty other individuals have pleaded guilty in connection with this case, including the former medical directors of Prime Care on the BayLLC and Bensonhurst Mega Medical Care P.C., six physical and occupational therapists, three ambulette drivers, the owner of several ofthe sham companies used to launder the money and a former patient who received illegal kickbacks.

Other Insurance Fraud Convictions

Insurance Broker Sentenced to 3 Years in Prison for $1.8M Scheme

Kimberly Graziano, of Middle Island, New York, a former insurance broker in Long Island, N.Y., whopleaded guilty to grand larceny and fraud has been sentenced to serve three to nine years in prison.

The Suffolk County District said on September 19, 2017 that 44-year-old Graziano must also pay $1.8million in restitution to her victims.

Prosecutors say Graziano falsified contracts totaling more than $1 million in funds stolen from an insurancecarrier.

Graziano’s schemes unraveled when her clients began having claims denied and had their drivers’ licenses suspended for lapses incoverage.

Eight Months for Several Crimes Including Insurance Fraud

Keith L. Shaffer, of Altamont, Kansas, was sentenced to eight months in prison for a wire fraud scheme that included the theft of fundsfrom Labette Bank and its insurance company subsidiary, as well as filing false tax returns.

The U.S. attorney’s office said in a news release that 61-year-old Shaffer will also have to serve four months of home confinement after hecompletes his prison term.

Jurors convicted Shaffer in November on charges of misapplication of bank funds, wire fraud, misappropriation of insurance funds andmaking false statements on a federal tax return.

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As manager of a bank subsidiary called Labette Insurance Co., Shaffer was a salaried employee of the bank. All commissions paid on salesby Labette Insurance belonged to the bank, but Shaffer diverted more than $134,000 in commissions on sales of insurance into his personalaccount, according to the U.S. Attorney’s office. As part of the scheme, Shaffer submitted false information to the bank and to the InternalRevenue Service.

Four to Prison For Roles in Staged Crashes

Michael Sine, of Fairmont, Bryce Martin, of Fairmont, Eric Warner, of Clarksburg, and Chasity Costilow, ofClarksburg, West Virginia, were sentenced tp prison for their involvement in a staged vehicle crash, faked injuriesand false insurance claims.

According to prosecutors, 34-year-old Sine, of Fairmont, was sentenced to almost three years and was ordered torepay more than $74,000 after pleading guilty to mail fraud for the 2013 Marion County crime.

In a related case, 26-year-old Martin was sentenced to six months from a staged crash, faked injuries and falseinsurance claim in 2012 in Harrison County. He was ordered to repay $152,000.

Also, 35-year-old Warner, of Clarksburg, was sentenced to 18 months and ordered to repay $152,000 from thatcrash.

Finally, 38-year-old Costilow, of Clarksburg, was sentenced to 21 months and ordered to repay $65,000 from a staged 2012 crash inMarion County.

Oregon Insurance Premium Financing Partners Guilty

Michael and Gary Holcomb pleaded guilty to one count of wire fraud conspiracy and one count of money laundering in the U.S. DistrictCourt for the District of Oregon. The brothers were former partners running Oregon-based insurance premium-financing businesses and

admitted to a wire fraud conspiracy and money laundering offenses valued at more than $40 million.

The brothers admitted they committed mail fraud from January 2008 through about Aug. 31, 2012. Four yearswithout any inquiry from police agencies in Oregon.

Berjac of Oregon and Berjac of Portland were family-owned businesses formed in the 1960s. The brothersbecame equal partners in the businesses in 1998 after having been partners in those and other Berjac businesses.

Both men solicited investors by telling them that the two companies offered safe andrelatively high returns on investments and that the businesses were prospering. The agreement said theHolcombs mailed quarterly statements to investors that falsely showed high rates of return and that investorshad earned interest.

The plea agreement said the companies acted as a Ponzi scheme in which they had not generated enoughreturns on which to pay interest and redemptions to investors.

The Holcombs propped up their struggling businesses by using investor money to obtain and use lines ofcredit from financial institutions and to pay investors. The Holcombs failed to disclose to investors that theyhad diverted the investors’ money for unauthorized uses, including defendants’ personal expenses, defendants’ vacation house, paymentson lines of credit and speculative real estate projects.

Premium financing is invariably at a high rate of interest and should, if run with some skill, would be highly profitable. It was easy to getinvestors in a low-interest-rate economy only to use the money to cheat customers.

ZIFL wonders why it took five years to get the plea and what criminal activities the brothers were involved in while awaiting trial.

Eight Convicted of Workers’ Compensation Fraud

Business owners, fraudulent claimants and a health care provider who attempted to steal from the Ohio Bureau of Workers’ Compensationare among eight convictions secured by the agency in August, the bureau announced on Friday.

The cases bring the year’s total convictions for state’s special investigations department to 100, the office reported.

Among those convicted last month, according to a press release:

Richard Rocco, Rocco Prosthetics and Orthotics, of Cincinnati, Ohio, submitted multiple physician’srequest for medical service forms without the knowledge or authority of the physicians whose namesappeared on the forms. Investigators seized from his clinic a master template and copies of blank formswith names and signatures of physicians. Mr. Rocco was ordered to pay restitution of $16,762.

Natoya Finley, doing business as Close to Home Child Development Center, of Cleveland, Ohio, andco-owner Rebecca Barbee-Whitt were operating the center without workers comp coverage. Ms. Finley is now required to report monthlycompliance with the established payment plan. Ms. Barbee-Whitt has a warrant for her arrest for failure to appear on the charges.

Thomas N. Jung, owner of Tom’s Industrial Truck Service, of Lima, Ohio, pleaded guilty to operating his business with lapsed workerscomp coverage. Mr. Jung was previously investigated in 2012 for lapsed coverage before bringing his policy into compliance. Jung’ssentencing is scheduled for Oct. 2. He will not receive jail time if he brings his policy into good standing prior to sentencing.

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Mark J. Cothern of Danville, Ohio, was found working at the Scoreboard Drive-in performing various duties while receiving temporarytotal benefits for workers comp. Mr. Cothern was sentenced to 180 days in jail, which was suspended for three years of community control,and required to obtain and maintain full-time employment and repay restitution in the amount of$9,406.46.

Alfred Bowlson of Toledo, Ohio, pleaded guilty to a fifth-degree felony count of workers comp fraudafter reporting wages for employment to the state for his work as a maintenance person in variousapartment complexes in the Toledo area while receiving comp disability. He was also receivingvocational rehabilitation and indicated he was discouraged at being unemployed and unable to providefor his family. Mr. Bowlson was sentenced to non-reporting community control for five years andordered to pay restitution of $18,501.46 to the BWC. He will serve 11 months in prison if he violatesthese terms.

Elton Rista, owner of ED & R Dining Services, of Avon Lake, Ohio, pleaded guilty to a second-degree misdemeanor count of failure tocomply after investigators found Mr. Rista was operating his business without workers comp coverage between June 2011 and August2015. Mr. Rista was sentenced to 90 days in jail (suspended) and two years of non-reporting community control. He must also payrestitution of $9,478, return to compliance with workers comp laws, and pay court costs.

Shardette Nyarko of Columbus, Ohio, pleaded guilty to one count of workers comp fraud after investigators found that Ms. Nyarko filedthree false claims stating she was injured at work when she was not even employed at the time. A judge fined her $100, then suspendedthe fine.

ZIFL can only wonder why, after all the work done to convict these people, the Ohio courts gave such minimal sentences.

Arson-for-Profit Results in Murder Conviction

Joseph A. Meyers was convicted in May 2017 of first-degree murder, arson, conspiracy and lesser charges for the Feb. 15, 2016 fire deathof 60-year-old David N. O’Dell in Wayland, New York.

The jury announced it had reached a verdict at 2:04 p.m. The jury found him “guilty” to first and second-degreemurder, two counts of arson, three counts of falsifying business records, attempted insurance fraud and conspiracy.The jury deliberated for about three hours, asking at one point to review text messages between Joseph Meyers andhis wife, Iryn Meyers, that were in evidence.

Iry Meyers is scheduled to go on trial for second-degree murder, arson, attempted insurance fraud and other chargeslater this year.

Prosecutors offered more than 120 exhibits, including text messages between Joseph and Iryn Meyers in which theydiscussed “being through with David,” video surveillance from Joseph Meyers residence/business, Loon Lake Services, and cell phonemapping that placed the defendant and his wife at or near O’Dell’s house in the late night and early morning hours of Feb. 14-15, 2016

The surveillance system provided video footage of the couple driving off three times toward O’Dell’s New Galen Road House, late Feb. 14and early Feb. 15, 2016. The video appeared to show Joseph Meyers carrying an extra pair of boots,and a large liquid container prior to one trip.

After the final trip, at about 1:15 a.m., Feb. 15, 2016, Iryn Meyers walks up the stairs leading to herresidence with what appears to be a propane torch under her left arm. Investigators believe the firestarted at about 1 a.m.

A Steuben County fire investigator could not say what caused the fire that leveled O’Dell’s home,leaving almost nothing standing. However, a New York state fire investigator testified that the firewas intentionally started in the basement and was accelerant based.

Joseph Meyers, 45, could face life in prison without the possibility of parole. Judge Joseph W. Latham did not set a sentencing date.

Barry Zalma, Inc. Provides the Following Services to its Clients:Acting as a consultant on behalf of insurers and insureds in litigation.

Acting as a consultant to the insured in the presentation of a first partyclaim.

Analysis of claims file material to allow the party to present evidence toestablish and document bad faith or the existence of a genuine disputebetween the insurer and insured.

Review of policy wording and claims files to determine if there is a basisfor payment or denial of a claim.

Analysis of insurance litigation for the insurer and the insured.

Consultation with insurance claims personnel on methods to avoid chargesof bad faith.

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Zalma's Insurance Fraud Letter -- Page 18 of 20

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Books from the American Bar AssociationThe Insurance Fraud Deskbook

Barry Zalma, Esq., CFE, 2014 Paperback, 638 Pages, 7x10

The Insurance Fraud Deskbook is a valuable resource, peer reviewed by the American Bar Association, for those who are engaged inthe effort to reduce expensive and pervasive occurrences of insurance fraud. It explains the elements of the crime and the tort toclaims personnel, and it provides information for lawyers who represent insurers so they can adequately advise their clients.Prosecutors and their investigators can use this book to determine what is required to prove the crime and win their case.

The full text of decisions from courts of appeal and supreme courts across the country are provided so the reader can understand whathappens after the investigation is completed and can apply that information to undertake their own thorough investigations. It allowclaims personnel and their lawyers to understand what errors would cause a defect or a not-guilty verdict.

The effort to reduce insurance fraud requires the assistance of both civil and criminal courts. The Insurance Fraud Deskbook can helpthe prudent fraud investigator, insurance adjuster, insurance attorney, insurance Special Investigation Unit and insurance companymanagement to attain the information needed to deal with state investigators and prosecutor. Available from the American BarAssociation at:

http://shop.americanbar.org/eBus/Default.aspx?TabID=251&productId=214624; or [email protected], or 800-285-2221.

Diminution in Value Damages How to Determine the Proper Measure of Damage to Real and Personal Property

This book was written to provide sufficient information to those who became interested in the issue since the GeorgiaSupreme Court decided State Farm Mutual Automobile Insurance Co. v. Mabry, 274 Ga. 498, 556 S.E.2d 114 (Ga.11/28/2001) and includes cases dealing with the use of diminution in value as a method of determining the amount of lossincurred by a plaintiff seeking indemnity for damage to real or personal property.

Because confusion has reigned across the United States concerning the proper measure of damages for property damageto property that has been repaired, Diminution In Value Damages assists the reader in answering the questionsconcerning the proper measure of damage in each of the fifty United States and federal United States jurisdictions

This edition has been totally rewritten and expanded, providing the most extensive and detailed coverage of the issue anda thorough explanation of how to apply diminution in value damages to losses to property.

ISBN: 978-1-63425-295-8, Product Code: 5190524, 2015, 235 pages, 7 x 10, Paperback

Available at http://shop.americanbar.org/eBus/Store/ProductDetails.aspx?productId=203226972

Zalma’s Insurance Fraud Letter© 2017 by Barry Zalma & ClaimSchool, Inc.

4441 Sepulveda Blvd, CULVER CITY CA 90230-4847

http://www.zalma.com # [email protected] # http://zalma.com/blog

ZIFL is made available by the publisher for educational purposes only as well as to give you general information and a generalunderstanding of the law, not to provide specific legal advice. By using ZIFL you understand that there is no attorney client relationshipbetween you and the publisher. ZIFL should not be used as a substitute for competent legal advice from a licensed professional attorney inyour state.

Zalma's Insurance Fraud Letter -- Page 19 of 20

The LegendMr. Zalma is the first recipient of the first annual Claims Magazine/ACE Legend Award, in 2016.

Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage,insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. Healso serves as an arbitrator or mediator for insurance related disputes. He practiced law in California for more than 44years as an insurance coverage and claims handling lawyer and more than 49 years in the insurance business.

Check in on Zalma’s Insurance 101 – a Videoblog – that allows your people to learn about insurance in three to fourminute increments at http://www.zalma.com/videoblog.

The American Bar Association, Tort & Insurance Practice Section has published Mr. Zalma’s book “The InsuranceFraud Deskbook” available at http://shop.americanbar.org/eBus/Store/ProductDetails.aspx?productId=214624, or800-285-2221 which is presently available and “Diminution of Value Damages” available athttp://shop.americanbar.org/eBus/Store/ProductDetails.aspx?productId=203226972

Mr. Zalma’s new e-books Heads I Win, Tails You Lose, The Law of Ethical Insurance Claims, the Insurance Law Handbook, CaliforniaInsurance Rescission Law Handbook, Random Thoughts on Insurance - Vol. IV, and Insurance Fraud & Weapons to Defeat Fraud wererecently added and are available at http://www.zalma.com/zalmabooks.html.

Look to National Underwriter Company for the new Zalma Insurance Claims Library, at www.nationalunderwriter.com/ZalmaLibrary Thenew books are Insurance Law, Mold Claims Coverage Guide, Construction Defects Coverage Guide and Insurance Claims: AComprehensive Guide.

Legal Disclaimer:

The author and publisher disclaim any liability, loss, or risk incurred as aconsequence, directly or indirectly, of the use and application of any ofthe contents of this blog. The information provided is not a substitute forthe advice of a competent insurance, legal, or other professional. TheInformation provided at this site should not be relied on as legal advice.Legal advice cannot be given without full consideration of all relevantinformation relating to an individual situation.

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