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Defendants claimed that their fraud was obvious so that the insurer was not harmed



When caregivers admit that they cheated an insurer but claimed they were not responsible because the fraud was so obvious that the insurer could not prove the element of reliability of common law fraud, their defense and appeal is cumbersome. I Government Employees Insurance Co., GEICO Indemnity Company, GEICO Casualty Company, GEICO General Insurance Company v. Quality Diagnostic Health Care, Inc., et al., Jorge E. Martinez, Luis Anibal Queral, MD, Moulton Keane, MD, Ivelis Garcia, Michel Viera, LMT no. 21-10297, United States Court of Appeals, Eleventh Circuit (November 5, 2021) the Eleventh Circuit refused to buy the ridiculous defense that it was GEICO's fault that they managed to defraud GEICO.

BACKGROUND

The appeal stemmed from a claim – filed by Defendant to GEICO – for reimbursement under the Florida Motor Vehicle No-Fault Law, Florida State. §§ 627.730-627.7405. Florida's No-Fault Law requires car insurance to include personal injury protection ("PIP") to provide medical injuries to people injured in car accidents. In accordance with a valid allotment of PIP benefits by the insured, the care provider can file a claim directly with the insurance company to receive payment for medical services rendered.

In Florida, an insurance company is not required to pay a claim for compensation under certain circumstances; including for a "person who knowingly makes a false or misleading statement regarding the claim or fees", "[f] or any processing or service that is encrypted", or for fees that "do not substantially meet the applicable" statutory requirements. Fault Law also prohibits compensation for services – including physiotherapy services – performed by massage therapists.

GEICO claimed that the defendants were involved in fraudulent billing practices through Quality Diagnostic Health Care, Inc. ("Quality"), a Florida healthcare clinic that claimed to provide patient examinations and physiotherapy for patients injured in car accidents.GEICO say Defendant filed or had fraudulent non-refundable insurance claims filed under Florida's No-Fault Law.

GEICO sought to recover insurance payments already made to Quality (approximately $ 145,000) and requested a declaration that GEICO was not liable. any legal obligation to pay the remaining outstanding claims filed by Quality (approximately $ 79,000). In applicable parts, GEICO claimed against the defendants for declaratory judgments, fraud under customary law, unfair enrichment and for violations of Florida law of fraudulent and unfair trading practices ("FDUTPA").

. The district court granted GEICO's request for a summary judgment. . The district court found that these facts were undisputed:

  1. The defendants submitted bills to GEICO which incorrectly increased the level of service during initial and follow-up patient examinations and were therefore coded;
  2. all physiotherapy services invoiced to GEICO had been performed by an unattended massage therapist permission to practice physiotherapy (corresponding to Viera); and
  3. the invoices submitted to GEICO incorrectly represented that physiotherapy services had been provided by or under the direct supervision of a licensed physician (corresponding to Keane). repayment under Florida's No-Fault Law. In view of the defendants' awareness of false representations, the district court also granted a summary judgment on GEICO's claims for fraud under law and for violations of FDUTPA.

    DISCUSSION

    Under Florida law, a plaintiff claiming fraud must show:


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