Posts Tagged ‘insurance claim’

What do Florida PIP claimants like to do? Sue, sue, sue.

Monday, July 14th, 2014

If you are wondering where your Personal Injury Protection (PIP) premiums go, look no further than the courthouse. More than half of Florida individuals and clinics hire lawyers to pursue insurance claims.

Those attorneys charge $300 to $500 an hour to fill out paperwork and shuttle it to the clerk of court. The lawyers then ask county court judges to approve their legal bills and order insurance companies to pay them. Sometimes, the lawyers who say they are working for the little guy collect tens of thousands of dollars when the client is seeking is a few dollars.

The percentage of PIP claimants nationwide represented by attorneys rose to 36 percent in 2012 from 31 percent in 2007, according to a study by the Insurance Research Council. It comes as no surprise to us or another auto insurer that Florida leads the nation, where more than half of claimants hired attorneys in 2012.

“The attorney involvement trends shown in this study undercut two of the envisioned benefits of no-fault auto injury systems: a less adversarial settlement process and more timely payments,”  Elizabeth Sprinkel, senior vice president of the council said in a press release. “The role of attorneys is implicated in many of the factors driving up the cost of auto insurance.”

The study found that in cases where attorneys represented claimants that individuals were much more likely than those without a lawyer to receive treatment in a pain clinic and were more likely to be involved in apparent claim abuse.

PIP fraud investigations have found that people involved in staged accidents and other illegal efforts to cheat the PIP system signed over their benefits to the clinic that was supposedly diagnosing and treating them. The clinics hired attorneys to sue auto insurance companies when the claims were investigated and sometimes denied.

The study was part of the council’s continuing research into auto injury claims. More than 35,000 auto injury claims were examined and 12 insurers that represent 52 percent of personal driver market participated.



What sets off the alarms in PIP fraud investigations? Not accidents

Sunday, April 20th, 2014

You don’t have to read more than a few posts here to know the biggest red flags for Personal Injury Protection (PIP) fraud. State, local and private investigators see them every day.

The National Insurance Crime Bureau has compiled what set off the alarms most often from 2010 through 2013:

  1. Faked or exaggerated injuries: nearly 5,000 referrals
  2. Medical provider: nearly 5,000
  3. Billing for services not rendered: 4,000-plus
  4. Excessive treatment: 4,000-plus
  5. Lack of cooperation from insured: about 2,900

Let’s look behind the numbers. Faked or exaggerated injuries relate to minor injuries that are made into big ones, or injuries that don’t exist except to file insurance claims. Until PIP reform, medical clinics could submit bills for up to $10,000 per person for an accident. In cases that later generated convictions, investigators found that people would be paid to say they were injured in car wrecks that never happened.

Medical providers would have the patients sign over their insurance benefits and send invoices to insurance companies. Investigators would look for patterns of activity that let them to question the claims. One suspicion: Services were not rendered.

When injuries were documented, investigators looked into whether there was excessive treatment. Again, in the days before PIP reform, clinics would schedule treatments right up to the dollar limit. When investigators sat down the people about their injuries and treatments, they sometimes encountered a lack of cooperation from the insured. Why was that? The lack of responses made investigators dig deeper.

Double the auto insurance fraud for Jacksonville resident?

Sunday, March 2nd, 2014

Stacy Lasondo Jackson has been charged in North Carolina with 10 counts of insurance fraud. But is it the first time she has committed this kind of crime?

Investigators with the N.C. Dept. of Insurance say that while she was living in Fayetteville, N.C., she obtained several thousand dollars from multiple insurance companies by filing fraudulent insurance claims for damage to her automobile and motorcycle between January and May 2013. They say that Jackson claimed the same vehicle was damaged more than once. Sometimes, there was no damage.

However, this may not be her first offense of this type. Jackson, 39, is from Jacksonville, Fla. According to North Carolina’s department of insurance, she was arrested on similar charges in Florida on Dec. 20, 2013. She lived in Jacksonville until she was extradited to North Carolina with the cooperation of Florida Dept. of Financial Services Division of Insurance Fraud and the Jacksonville Sheriff’s Office.

On Feb. 25, Jackson was arrested by N.C. Dept. of Insurance criminal investigators and placed under a $10,000 bond.

One-armed man behind PIP fraud: Really

Thursday, December 19th, 2013

Three people have been arrested and charged with Personal Injury Protection (PIP) fraud, and one of them says a one-armed man was to blame.

The Sun-Sentinel reports that Donicio Ruiz, 34, told investigators that a one-armed man recruited him to be the other driver in a staged accident in West Palm Beach. Two women, driver Marilu Rodriguez, 26, and passenger, Monica Riveron, 34, also told police that they were injured. They went to a clinic where false insurance claims for PIP benefits were filed.

Ruiz told investigators that the one-armed man paid him $1,500 a week after the accident. Rodriguez said she was paid $1,000, but didn’t identify the person.

The staged accident was reported on May 5, 2010. Rodriguez confessed to an FBI agent in October 2011 that she was paid to set up the accident and file false claims. The trio was arrested in early December 2013.


Florida PIP reform law stays in place as 1st District Court of Appeals denies motion for rehearing

Tuesday, November 26th, 2013

The Florida Personal Injury Protection (PIP) reform law enacted in 2012 has withstood another legal challenge as the 1st District Court of Appeals denied a motion for rehearing on its reversal of an injunction that prevented a significant part of the law from taking effect.

In March, a coalition of acupuncturists, chiropractors and licensed massage therapists persuaded a Leon County circuit court judge to grant a temporary injunction that blocked the portion of the law banning payments to them and requiring that injured person seek treatment within 14 days of an accident from a physician or hospital except under certain conditions.

Those provisions were put in place because of widespread PIP fraud in Florida. Much of that fraud was generated through falsified claims for medical need and treatment.

The victory for those business groups was short-lived, as the 1st District Court of Appeals reversed the circuit court on Oct. 23. The appeals court said the business groups failed to show a specific instance that supported their claim of denial of access to the courts. The court also said that the claim of economic harm was insufficient to assert the potential access-to-courts claims of other parties.

“The real parties in interest—injured motorists whose ability to sue tortfeasors has been impermissibly limited—are absent from this case,” the court wrote in a unanimous decision. “The Provider Plaintiffs’ attempt to bootstrap the standing requirement by joining the fictional ‘Jane Doe,’ purporting to represent all Florida citizens that were, are, or will be injured as a result of a motor vehicle collision, must likewise fail. The instant record does not provide a factual context or legal basis to support this hypothetical claim.”

The business groups were denied a rehearing in late November, which means those provisions of the PIP reform law will remain in effect unless the business groups file a successful appeal with the Florida Supreme Court.

“In order for Florida to no longer be the No. 1 state in the nation for questionable auto claims, and stop the $1 billion fraud tax on Florida consumers, the PIP reforms passed by the Legislature must have time to be fully implemented,” Donovan Brown, state government relations counsel for the Property Casualty Insurers Association of America, told the website Property Casualty 360.

“We are cautiously optimistic that once these reforms are fully implemented and have been given time to work, the fraud and abuse in Florida’s no-fault auto insurance system that so adversely impacts Floridians will subside, and Florida consumers may be provided with much needed relief once and for all,” he said.

Who is preying on drivers? Looks like PIP fraudsters

Monday, September 16th, 2013

The masterminds of Personal Injury Protection (PIP) fraud rarely put themselves in danger. They hire people to crash cars and file false police reports. Those average folk take big risks for a few bucks, while PIP fraud organizers collect the lion’s share of the money from insurance companies.

So, when we hear that auto insurance companies are taking advantage of consumers, we point to Faika Khader, who was short on cash and ideas how to get it. She told police that she needed $900 and signed on to a PIP fraud scheme to earn the money.

In August 2011, Khader crashed her Dodge minivan into a car at an intersection in Boynton Beach. She filed a PIP claim with Farmers Insurance at Apex Chiropractic & Rehab Center in West Palm Beach.

She later admitted to a Farmers Insurance investigator that a man she did not previously know gave her $900 to buy an auto insurance policy. On the night of the crash, he gave her instructions on what to do after the accident, and urged her to add passengers to her van. In return, he promised her several thousand dollars.

When the Florida Department of Financial Service’s Fraud Division became involved, Khader slightly changed her story, but the essentials were the same: Cause a crash, file a PIP claim, go to the clinic, and receive $2,000.

Khader was arrested, but the two strangers who rode in her minivan were not found. She’s in the most trouble, while the scammers – including the mystery man who recruited her – have moved on. We expect that they will resurface: clinic operators that police shut down often re-open in other counties, sometimes hiding their true identities.

We might not sympathize with Khader, but we can understand why she committed the crime: She needed the money. The real victims are the driver of the car she hit and all of us, who pay higher auto insurance premiums because the laws aren’t tough enough on PIP fraud.

New PIP law clamps down on fraud by requiring truthful statements

Friday, July 12th, 2013

Hypothetical: A person who claims to be injured in an auto accident is asked to state under oath what happened. On some auto insurance policies, such sworn statements are required as a condition of approving Personal Injury Protection (PIP) claims.

Why? To fight PIP fraud, which is rampant in Florida. Auto insurers want to know that a claim is legitimate before writing a check.

Real world: The Florida Supreme Court says that insurance companies can no longer require people who made claims before Jan. 1 to sit for a legal examination. The court said that the requirement delays and denies benefits, contrary to the intent of an old PIP law to pay benefits as quickly as possible.

The likely result? Higher PIP premiums for a while. Stripped of that legal tool, auto insurers cannot scrutinize claims as closely. More PIP fraud means more insurance payouts, which means higher auto insurance rates.

Some Florida Supreme Court justices thought that legal examinations were reasonable. In a dissenting opinion issued June 27, Justice Charles Canady wrote: “The right to a ‘swift and virtually automatic’ recovery of benefits is a right properly enjoyed by those who in fact meet the legal requirements for the receipt of benefits and comply with the legal obligations of an insured. The EUO [examination under oath] provision of the policy is simply designed to ensure that the ‘swift and virtually automatic’ payment of benefits is made only to those who are entitled to those benefits under the law.”

The PIP reform law that took effect this year corrects the situation. It enables auto insurance companies to include examinations under oath in an insurance policy. Once the backlog of PIP claims clears – a process that could take years – a more balanced approach will be restored.

Pain clinic defrauds Miami-Dade County with fake insurance claims

Tuesday, May 7th, 2013

The bus drivers weren’t hurt in accidents, but you couldn’t tell that from the hundreds of insurance claims. The scam is over, halted by authorities who say they busted the scheme to defraud Miami-Dade County’s health insurance plan of tens of thousands of dollars.

The Miami-Dade public corruption bureau arrested six top executives of AZJ Medical Center in Miami and put out an arrest warrant for company president Elvis Garcia, who had left the building. The alleged perpetrators were charged with filing false insurance claims, grand theft, organized scheme to defraud, and patient-brokering.

This is standard stuff at the clinics that rip off insurance companies and drivers on Personal Injury Protection (PIP) claims. Organizers fabricate records of injuries and treatments and bill the insurer for the maximum amount. Sometimes, crews stage accidents to generate more claims.

At AZJ, operators recruited transit workers so the medical center could file phony claims with the insurance company administering the self-funded county plan. One bus driver generated billings for 135 visits and 758 treatments. But police say that the individual received only a handful of massages. Another worker signed blank medical forms that were turned into invoices.

One informant told investigators that she was paid more than $6,000 in cash to provide her name and insurance policy for fake claims and to recruit others to the scam. A clinic employee told police that he received $45 from the bosses each time he signed off on progress forms for patients he never treated.  Another employee signed off on forms for patients seen by a massage therapist who pretended to be an occupational therapist.

Those are common practices at clinics that engage in PIP fraud. Injuries and treatments are invented and become insurance bills. At the AZJ clinic, authorities first arrested seven transit workers on charges they were part of an insurance swindle. A year later, police had enough evidence to go after the ringleaders.

Sometimes, victim of PIP fraud is not just the insurance company, but the patient

Tuesday, April 23rd, 2013

A patient of Polo Medical Center in Delray Beach was more than a little surprised when she saw the number of Personal Injury Protection (PIP) insurance claims for her auto accident. She had gone to the chiropractic clinic for treatment and stopped two weeks later; however, her insurance company was billed for another 10 weeks of appointments.

When the patient notified her insurance company, it found that the clinic had billed $9,468, which is just under the $10,000 PIP limit. The clinic’s chiropractor, Barbara Ann Turkell-White, initially said the amount was a clerical error and made a partial refund. Further review found 24 false therapy notes.

The Florida Division of Insurance Fraud investigated and arrested Turkell-White in February on charges of insurance fraud and grand theft.

The lesson: You could be a victim of PIP fraud and not know it. Check your insurance claim statements for accuracy. Otherwise, a clinic could charge your insurer for services never provided and no one would be the wiser. However, you would be poorer because everyone pays for PIP fraud.

Last member of ‘Operation Whiplash’ ring convicted of PIP fraud

Monday, April 22nd, 2013

We reported that Stephen M. Lovell of Windmere was among those arrested on federal charges of Personal Injury Protection (PIP) fraud. Now, we can tell you that he was convicted.

Lovell was found guilty of conspiracy to commit health care fraud and could go to federal prison for up to 20 years. He is scheduled to be sentenced June 10.

Lovell, a chiropractor, had claimed that was president and sole officer of Xtreme Care Rehabilitation Center Inc. in Cape Coral. In fact, he was acting as a front for the real owners so that they could avoid government regulation as a health clinic.

The clinic was a sham in other ways. Lovell and the 11 others, all of whom have pleaded guilty, recruited people to stage auto accidents and filed fraudulent PIP claims on their behalf. Once paid by insurance companies, the conspirators laundered the proceeds through corporate bank accounts.

A number of agencies played important roles in uncovering the fraud in what they code-named “Operation Whiplash.” They were the Cape Coral police department, Secret Service, IRS criminal investigation, city of Miami police, Hialeah police department, Florida Dept. of Financial Services and National Insurance Crime Bureau.