MIAMI — A Florida appeals panel on June 26 ordered a new trial over an insurance company’s denial of a woman’s claim under her homeowners policy to recover losses stemming from a January 2010 burglary, holding that the trial court judge erred when striking the insurance company’s affirmative defense for insurance fraud and not giving the company leave to amend the defense (American Integrity Insurance Company v. Maria Estrada, No. 3D16-966, Fla. App., 3rd Dist., 2019 Fla. App. 10020).
BIRMINGHAM, Ala. — A federal judge in Alabama ruled June 24 that a Nigerian woman cannot introduce evidence of cultural differences to support her defense that she was coerced and in a state of duress when she submitted fraudulent bills to Medicare and private insurers for allergen immunotherapy for patients when it was medically unnecessary, explaining that the defendant did not provide any examples of what evidence she would submit (United States v. Patrick Emeka Ifediba, et al., No. 18-cr-0103-RDP-JEO, N.D. Ala., 2019 U.S. Dist. LEXIS 104710).
HATTIESBURG, Miss. — A federal magistrate judge in Mississippi on June 24 scheduled an Aug. 18 trial date for a physician and a pharmacist charged with submitting more than $7 million in bills for medically unnecessary compounded medications to TRICARE, the health care benefit program serving U.S. military, veterans and their respective family members, and private health care benefit programs (United States v. Shahjahan Sultan, M.D., et al., No. 19cr28, S.D. Miss.).
ATLANTA — A Georgia appeals panel on June 19 upheld a trial court judge’s affirmation of an administrative law judge’s (ALJ) decision that an insurance company waived its void policy defense when seeking to deny coverage of a workers’ compensation claim, holding that the company decided to cancel a construction company’s policy over misrepresentations in the policy application rather than rescind the policy (Grange Mutual Casualty Company v. Adam Bennett, et al., No. A19A0497, Ga. App., 4th Div., 2019 Ga. App. LEXIS 339).
ST. LOUIS — A man who used the name and nursing license of an actual licensed registered nurse to obtain a position at a rehabilitation facility and used other personal information to rent apartments, take out loans and lines of credit and apply for insurance policies was sentenced to 57 months in prison by a federal judge in Missouri on June 12 (United States v. Benjamin D. Danneman, No. 19cr202, E.D. Mo.).
BALTIMORE — A federal judge in Maryland on June 11 dismissed without prejudice counterclaims for defamation, civil conspiracy and tortious interference with prospective business advantage brought by medical clinics and health care providers accused by State Farm Mutual Automobile Insurance Co. of submitting fraudulent bills for no-fault benefits coverage, finding that claim denial letters did not include defamatory statements and that the allegations did not support a claim for civil conspiracy (State Farm Mutual Automobile Insurance Co., et al. v. Slade Healthcare Inc., et al., No. ELH-17-3696, D. Md., 2019 U.S. Dist. LEXIS 98374).
MIAMI — A federal judge in Florida on June 3 granted in part a doctor and clinic owner’s motion to dismiss a lawsuit brought by State Farm Mutual Automobile Insurance Co., finding that while the insurer can pursue a claim under the Florida Deceptive and Unfair Trade Practices Act (FDUTPA) for the defendants’ submission of more than 1,700 allegedly fraudulent bills, it must amend its allegations to comply with the heightened pleading requirement of Federal Rule of Civil Procedure 9(b) (State Farm Mutual Automobile Insurance Company v. Manuel V. Feijoo, et al., No. 18-cv-23329-KMM, S.D. Fla., 2019 U.S. Dist. LEXIS 93343).
LOS ANGELES — A California appeals panel on June 17 affirmed a jury’s decision to order two women to pay $6.3 million for violating California Penal Code Section 550 when creating sham law firms to submit fraudulent claims to Allstate Insurance Co., finding that the trial court judge did not abuse his discretion when denying one defendant’s ex parte motion for a stay and that the defendants’ submission of claims from sham firms violated the statute (People, ex rel. Allstate Insurance Company, et al. v. Christine Suh, et al., No. B280293, Calif. App., 2nd Dist., 7th Div., 2019 Cal. Unpub. LEXIS 4058).
MIAMI — The owner of a pharmacy and pain management clinic was sentenced to 78 months in prison and ordered to forfeit $1.4 million by a federal judge in Florida on June 14 after the man pleaded guilty for his role that involved the submission of $2.2 million in fraudulent claims to Medicare (United States v. Scott Novick, No. 18-cr-20563, S.D. Fla.).
DETROIT — A federal magistrate judge in Michigan on June 14 denied a motion to quash a subpoena for a deposition filed by the manager of an imaging clinic who is not a party to fraudulent billing scheme lawsuit brought by State Farm Mutual Automobile Co., finding that it would not pose an undue burden (State Farm Mutual Automobile Insurance Company v. Elite Health Centers Inc., et al., No. 16cv13040, E.D. Mich., 2019 U.S. Dist. LEXIS 99897).
BIRMINGHAM, Ala. — An Alabama federal judge on June 14 denied a motion to remand filed by insureds alleging claims for breach of contract and bad faith arising out of a water and mold damage claim after determining that the insurers produced sufficient evidence showing that the amount in controversy exceeds the federal jurisdictional minimum of $75,000 (Matthew B. Menendez, et al. v. American Strategic Insurance Corp., et al., No. 19-443, N.D. Ala., 2019 U.S. Dist. LEXIS 99975).
ALBANY, N.Y. —New York’s highest court on June 11 affirmed an appeals court’s ruling that stood by a jury’s verdict that 54 New York automobile insurers and self-insurers are not responsible for paying $20 million in pending claims because a physician did not own and control the professional medical corporation under whose name he sought to collect first-party no-fault benefits from the insurers, finding that the lower court did not err in declining to give a jury charge that required a finding of fraudulent intent or conduct that was "tantamount to fraud" to reach its verdict in the insurers’ favor (Andrew Carothers, M.D., P.C. v. Progressive Insurance Company, No. 39, N.Y., App., 2019 N.Y. LEXIS 1641).
ALBANY, N.Y. — A New York pharmacist on June 5 entered into an agreement with the federal government in New York federal court to pay $100,000 to resolve allegations that she violated the federal False Claims Act (FCA) as well as the state’s version of the statute when falsely billing Medicare and Medicaid from March 2010 through March 2017 for prescriptions that were never dispensed to patients (United States, ex rel. Barbara Lopez v. Nassau Pharmacy, No. 16-cv-1338, N.D. N.Y.).
CHICAGO — A federal judge in Illinois on May 30 accepted a woman’s change of plea from not guilty to guilty on one charge of conspiracy to commit health care fraud for her role in the submission of $1.7 million in false bills to the U.S. Department of Labor’s Office of Workers Compensation Programs (OWCP) for constant treatment of one patient that she was not providing (United States v. Chante Carrothers, et al., No. 18cr374, N.D. Ill.).
CLEVELAND — An Ohio appeals panel on May 30 affirmed the denial of a man’s delayed motion for a new trial after he was found guilty of insurance fraud and aggravated arson, holding that a U.S. Supreme Court’s ruling did not constitute newly discovered evidence that warranted the delay (Ohio v. Dale Rodano, No. 107880, Ohio App., 8th Dist., 2019 Ohio App. LEXIS 2178).
TUCSON, Ariz. — A federal judge in Arizona on May 20 sentenced a podiatrist who submitted fraudulent bills to Medicare for procedures that were never performed on patients in assisted living facilities to 24 months in prison (United States v. Loren Wessel, No. CR-17-978, D. Ariz.).
HARRISBURG, Pa. — A Pennsylvania appeals panel on May 21 vacated in part a lower court judge’s ruling suppressing the admission of a draft report prepared by an expert regarding the cause of a fire that was allegedly started to submit a fraudulent insurance claim, ruling that a search warrant issued to obtain the report was valid and that the report was not protected from disclosure by the work product doctrine (Pennsylvania v. Shawn Anthony Schaefer, No. 1204 WDA 2018, Pa. Super., 2019 Pa. Super. Unpub. LEXIS 1981).
ATLANTA — A chiropractor’s 84-month sentence for engaging in a scheme to submit fraudulent claims to insurance companies for patients who were purportedly injured as a result of staged auto accidents was affirmed by an 11th Circuit U.S. Court of Appeals panel on May 20, but the panel vacated the amount of restitution he must pay because some claims may have been filed before he was hired by a clinic that participated in the scheme (United States v. Hal Mark Kreitman, No. 18-12838, 11th Cir., 2019 U.S. App. LEXIS 14760).
BATON ROUGE, La. — The co-owner of a pain management clinic was sentenced by a federal judge in Louisiana on May 17 to 37 months in prison for his role in a fraudulent billing scheme that involved unbundling nonreimbursable office visits from minor surgical procedures and submitting the visits to Medicare (United States v. John E. Clark, No. 17cr85, M.D. La.).
MCALLEN, Texas— A woman who owned a medical equipment company was sentenced by a federal judge in Texas May 9 to 78 months in prison after she pleaded guilty to one count of health care fraud for fraudulently billing Texas Medicaid for incontinence supplies provided to beneficiaries (United States v. Anna Ramirez-Ambriz, No. 17cr56, S.D. Texas).