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

knew that the defendant's allegations incorrectly represented the nature and scope of the patient examinations. According to the defendants, the invoicing deficiencies were "obvious" from the underlying treatment records and accident reports (to which GEICO had access) and GEICO was therefore informed that the defendants' commitments on their reimbursement invoices were false.

the district court rightly rejected these arguments. Under Florida law, a person can "rely on the truth of a representation, even if its falsity could have been established if he had conducted an investigation, unless he knows that the representation is false or that its falsity is obvious to him." [ Besett v. Basnett 389 So.2d 995, 998 (Fla. 1980)]

A falsehood is "obvious" when "a mere clear glance would have revealed the falsehood of the representation" or when a "clear investigation or investigation "would make" patent "the forgery. In the context of insurance, we have said that – in the absence of "any circumstance that draws attention to them" – information anywhere in an insurer's register is insufficient to make an insurer aware of the inaccuracy in petitions made to it. See Schrader v. Prudential Ins. Co. 280 F.2d 355, 362 (5th Cir. 1960) which stated that an "insurer has the right to rely on an insured's representations without checking all of its files to determine if the insured is committing fraud."

The Eleventh Circuit could not establish that the falsity of the defendants' erroneous submissions was "obvious". a more thorough examination of the complete treatment records and accident reports could have revealed the falsity of the defendants' statements.

UNFAIR ENRICHMENT & FDUTPA

To file a claim for unfair enrichment under Florida law, a plaintiff must prove three factors:

• the plaintiff granted the defendant a benefit;
• the defendant voluntarily accepted and retained the defendant. that advantage; and
• the circumstances are such that it would be unfair for the defendants to retain it without paying the value of it.

receive in the first place. GEICO paid the defendant over $ 145,000 in compensation for patient examinations and for physiotherapy services allegedly provided by Quality. It is common ground that the Defendant's claims – as they have been submitted – were not repayable under Florida's No-Fault Law. Since the defendants had no legal right to the compensation payments, the district court did not err in granting GEICO a summary judgment on its claim to unauthorized gain.

or unfair commercial practices; (2) causation; and (3) actual damage. " [ See Dolphin LLC v. WCI Cmtys., Inc. 715 F.3d 1243, 1250 (11th Cir. 2013).] The district court concluded that GEICO was entitled to a summary judgment because the defendants have recognized engaged. "fraudulent acts" or "unfair trading practices" when they coded fees and falsely represented that Dr. Keane performed or directly supervised the physiotherapy services and (2) there was a causal link between the defendants' misleading actions and GEICO's payment of the PIP claims.

It takes a lot of inability to appeal an unfavorable verdict after admitting that the behavior that resulted in a summary judgment in favor of GEICO was unpleasant because they admitted that they had cheated GEICO and raised the silly argument that GEICO should not have paid the fraudulent billing because they were obviously fraudulent. I can only wonder why the defendants or their lawyers were not sanctioned for raising such a frivolous appeal.

© ​​2021 – Barry Zalma

Barry Zalma, Esq., CFE, now limits his practice to the position of insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders.

He also acts as an arbitrator. insurance-related disputes. He practiced law in California for more than 44 years as a lawyer for insurance coverage and claims management and more than 54 years in the insurance industry.

Subscribe to Excellence in Claims Handling at https://barryzalma.substack.com/welcome.

He is available at http://www.zalma.com and zalma@zalma.com. Zalma is the first recipient of the first annual Claims Magazine / ACE Legend Award. For the past 53 years, Barry Zalma has devoted his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to enable insurers and their claimants to become professionals in insurance claims.