Mealey's Insurance Fraud : Mealey's : Legal News & Analysis

Mealey's Insurance Fraud

March 05, 2025
11th Circuit Transfers GEICO Attorney Fee Motion To District Court In Fraud Suit

ATLANTA — The 11th Circuit U.S. Court of Appeals granted a motion filed by GEICO to transfer its motion for appellate attorney fees to a district court that entered a $690,251.44 judgment for the insurer in its suit against a health care clinic and related parties for allegedly submitting fraudulent no-fault insurance charges.
March 05, 2025
Judgment Denied To Life Policy Beneficiary Over No Incarceration Disclosure

HOUSTON — A Texas federal judge denied a life insurance policy beneficiary’s motion for summary judgment in her breach of contract suit against an insurer for its failure to pay benefits under the policy, finding that the insurer is entitled to cancel the policy due to the beneficiary’s failure to accurately represent the insured’s criminal history in the policy application.
March 03, 2025
Mich. High Court Won’t Review Ruling Affirming Summary Disposition For Allstate

LANSING, Mich. — Finding that it was “not persuaded that the questions presented should be reviewed by this Court,” the Michigan Supreme Court denied an auto insurer’s application for leave to appeal a Michigan appellate court’s ruling affirming a lower court’s grant of summary disposition in favor of Allstate Insurance Co. in its suit against the auto insurer, seeking reimbursement for $521,872.82 in personal injury protection (PIP) benefits Allstate paid on behalf of a man fatally injured in a moped accident.
March 03, 2025
Judgment Granted For Insurer In Row Over Sinking Vessel Coverage, Policy Voidance

MIAMI — A Florida federal judge adopted a magistrate judge’s report and recommendation to grant summary judgment to an insurer in its declaratory judgment suit seeking to void a marine policy for material misrepresentations and to deny coverage for the partial sinking of a vessel, finding that the magistrate judge correctly determined that the policy was voided due to an inaccurate answer to a policy application question that was material to the decision to issue the policy.
March 03, 2025
5th Circuit Affirms Dismissal Of Chiropractor’s Claims In Insurance Billing Row

NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals on Feb. 28 affirmed a lower court’s dismissal of a chiropractor’s fraud and breach of contract claims against a company with whom she contracted to perform independent medical examinations (IMEs) for workers’ compensation claims, finding that the lower court correctly dismissed the suit because she failed to show an injury in fact related to her claims that the company overbilled insurers for her services.
March 03, 2025
Reinsurer, Agency Dismiss RICO, State Claims In Fraudulent Injury Case

BROOKLYN, N.Y. — A reinsurer and a management general agency were granted permission by a New York federal court to dismiss claims against an ambulatory surgery center in an ongoing Racketeer Influenced and Corrupt Organizations Act (RICO) lawsuit alleging fraudulent workers’ compensation claims and personal injury lawsuits.
February 27, 2025
5th Circuit Reverses Ruling Denying Judgment To Planned Parenthood In FCA Suit

NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals on Feb. 27 reversed and remanded a lower court ruling denying summary judgment to Planned Parenthood for implied false certification and conspiracy claims in a relator’s False Claims Act (FCA) suit accusing Planned Parenthood of failure to repay Medicaid reimbursements received while injunctions were in force in underlying litigation, finding that Planned Parenthood was entitled to summary judgment due to the immunity for its attorneys’ acts.
February 27, 2025
GEICO Seeks To Recover Over $2.75M In ‘Fraudulent’ PIP Claims From Florida Clinics

MIAMI — GEICO filed a complaint in a Florida federal court against multiple health care clinics and their owners, seeking to recover over $2.75 million in payments it says were wrongfully obtained for “fraudulent and unlawful” personal injury protection (PIP) claims related to alleged medically unnecessary health care services.
February 25, 2025
Insurer Answers Counterclaim In Suit Over Misrepresentation About Auto Body Shop

MINNEAPOLIS — A commercial general liability insurer filed an answer to its insureds’ counterclaim in a fire coverage dispute over whether the insurer is entitled to rescind the policy for the insureds’ purported misrepresentation for failure to disclose that an auto body shop operated on their premises.
February 21, 2025
Judgment As A Matter Of Law Denied In Murdaugh Housekeeper Estate Coverage Row

CHARLESTON, S.C. — A South Carolina federal judge on Feb. 20 denied a motion for judgment as a matter of law filed by an insurer after a South Carolina jury returned a $1.25 million verdict in favor of the insurer in its suit seeking a declaration that it is entitled to recover the full $3.8 million it paid to settle a claim brought by the estate of Alex Murdaugh’s former housekeeper, finding that though the jury found an attorney liable for violations of state law, the firm where he worked provided evidence that he “acted outside of the scope of his employment.”
February 19, 2025
1st Circuit Affirms Ruling In DOJ ‘First Impression’ FCA Suit Against Regeneron

BOSTON — The First Circuit U.S. Court of Appeals on Feb. 18 affirmed a lower court ruling granting summary judgment to Regeneron Pharmaceuticals in a U.S. Department of Justice (DOJ) suit alleging violations of the federal False Claims Act (FCA) and the Anti-Kickback Statute (AKS) regarding purported improper funding of the Chronic Disease Fund (CDF) to subsidize patient copays for a Regeneron macular degeneration drug, finding that in this case of “first impression” regarding a 2010 amendment to the AKS, to show falsity under the amendment, the government must prove “that an illicit kickback was the but-for cause of a submitted claim.”
February 19, 2025
After Voluntary Dismissal By Insurers’ Receiver, Judge Tosses $300M Ponzi Case

MIAMI — After a receiver for insolvent insurers and related entities filed a notice of voluntary dismissal, a Florida federal judge issued a docket-only entry dismissing without prejudice Wells Fargo in the receiver’s suit alleging that Wells Fargo aided and abetted fraud in a “massive” Ponzi scheme purportedly orchestrated by owners of insurers, some of which are now in receivership, resulting in elderly investor victims losing more than $300 million after scheme operators sold them promissory notes secured by collateral in stranger-oriented life insurance policies (STOLIs).
February 18, 2025
4th Circuit: First To File Applies, Dismissal Correct In FCA Hospice Fraud Suit

RICHMOND, Va. — The Fourth Circuit U.S. Court of Appeals on Feb. 14 affirmed a lower court’s dismissal of a qui tam relator’s suit alleging violations of the federal False Claims Act (FCA) by a hospice provider and related entities for improper admissions to hospice, finding that though the lower court should have addressed the amended complaint, it correctly dismissed her claims under the first-to-file rule because of a previously filed similar case against some of the same defendants.
February 18, 2025
Judgment Partially Granted For Homeowner In Row Over More Than $1M In Water Damage

GREENVILLE, N.C. — A North Carolina federal judge granted in part a homeowner’s motion for judgment on the pleadings in a dispute with her homeowners insurer over its duty to indemnify her for the alleged fraudulently obtained appraisal award of $1,036,000 for the purported water damage to her home, finding that the claim for inclusion of expenses not actually incurred is dismissed for failure to state a claim, but dismissal of all other claims is denied.
February 13, 2025
COMMENTARY: The Top Twelve Insurance Coverage Decisions Of 2024

By Robert D. Chesler, Seán McCabe, Madilynne Lee and James A. Goodridge
February 12, 2025
Partial Judgment Granted To Allstate In Coverage Row Over Fire Damage Claim

BEAUMONT, Texas — A Texas federal judge partially granted summary judgment to Allstate in a coverage dispute where Allstate says its insured is barred from recovery for fraud in submitting a claim for loss related to the fire he allegedly set at his home, finding that the insured cannot raise a fact dispute on his bad faith and unfair settlement practices counterclaims due to a lack of clarity regarding liability and that he lacks evidence to support his counterclaim for unreasonable delay of payment.
February 12, 2025
Partial Dismissal Granted In Hail Damage Coverage Row Over Roof Tile Replacement

DENVER — A Colorado federal judge on Feb. 11 granted in part homeowners’ motion to dismiss a misrepresentation counterclaim in a breach of contract suit against their homeowners insurer over the cost to repair their hail-damaged roof, finding that though the counterclaim failed to allege knowing misrepresentation, the homeowners failed to provide any argument to support their request for dismissal with prejudice.
February 11, 2025
Ruling Denying EUO Petition Vacated In Row Over Auto Accident Chiropractic Claims

FRANKFORT, Ky. — A Kentucky appellate court vacated and remanded a lower court ruling denying Allstate’s petition for an examination under oath (EUO) of individuals involved in an auto accident who sought personal injury protection (PIP) through Allstate for reimbursement for chiropractic medical treatment, finding that the lower court erred in failing to recognize Allstate’s entitlement “to at least inquire into how the accident happened at an EUO.”
February 11, 2025
Depositions Stayed, Intervention Ruling Deferred In GEICO $1M No-Fault Fraud Suit

BROOKLYN, N.Y. — A New York federal magistrate judge on Feb. 10 deferred ruling on the U.S. government’s motion to intervene but granted its motion to stay depositions for 90 days in a no-fault insurance fraud suit alleging that the defendants, some of whom have been indicted in a related criminal case, participated in a “scheme” to submit to GEICO for payment fraudulent no-fault insurance charges of more than $1 million, finding that the government showed that a stay is warranted but failed to indicate whether the parties consented to intervention.
February 11, 2025
Insurer Seeks To Void Policy Over Prior Policy Cancellation Misrepresentation

CHICAGO — An Arizona-based insurer sued its insured gym operator seeking to rescind a commercial lines policy based on the insured’s purported misrepresentations in the policy application by not providing information about a lapse in coverage, a nonrenewal due to a history of loss and a cancellation for nonpayment, arguing that the insurer would have issued the policy under different conditions, if at all, if the insured had provided accurate information.
February 11, 2025
Insurer Amends Complaint Against Surgeon In Fraud Suit Alleging ‘False Treatment’

BROOKLYN, N.Y. — A Vermont-based insurer filed an amended complaint in a New York federal court in its fraud suit against a New York-based spinal surgeon, alleging that he participated in a “scheme” to defraud the insurer by submitting claims for reimbursement regarding “false treatment” and surgeries for injuries purportedly unrelated to incidents covered under the insurer’s policies.
February 10, 2025
Judgment Affirmed For Staffing Agency In Insurance Fraud Prevention Act Dispute

TRENTON, N.J. — A New Jersey appellate court on Feb. 7 affirmed a lower court’s grant of summary judgment to a medical staffing agency and its parent company in a suit accusing them and related entities and individuals of medical malpractice, negligence and violation of the New Jersey Insurance Fraud Prevention Act (IFPA) related to the role of the agency’s client, an orthopedic provider, in administering knee injections resulting in an infection outbreak, agreeing with the lower court’s determination that the agency had “no role in the formation or operation” of the provider’s practice.
February 07, 2025
Massachusetts Panel Reverses Dismissal Of Auto Coverage Dispute Over Alleged Fraud

BOSTON — A Massachusetts appellate court reversed a lower court ruling that “allowed” a motion for summary judgment and dismissed an insurer’s suit seeking a judgment that it had no duty to defend its insured for claims brought against her related to an auto accident, finding that the policy exclusion for driving a vehicle not added to the policy applied whether or not the insured made an alleged misrepresentation by failing to report a change in her marital status.
February 06, 2025
Partial Dismissal Of Counterclaims Granted In $3.3M Health Care Fraud Dispute

ANCHORAGE, Alaska — An Alaska federal judge on Feb. 5 granted in part a motion to dismiss counterclaims in a fraud suit filed by an Alaska health insurer against a California treatment facility alleging approximately $3.3 million of fraudulent claims related to the facility purportedly falsifying income of prospective patients when enrolling them in the health insurer’s plan, finding that the bad faith counterclaims should be dismissed as not adequately pleaded and that there is no private right of action pursuant to an Alaska statute.
February 04, 2025
Del. High Court Affirms Ruling Setting Aside Verdict In Insurance Coverage Dispute

DOVER, Del. — The Delaware Supreme Court on Feb. 3 affirmed a lower court judge’s ruling granting an insured’s motion for a new trial in a professional liability coverage dispute arising from a Medicaid fraud investigation, finding that the judge did not ignore the law in setting aside a jury verdict.