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Pre-existing condition Material without error claim
No non-life insurance plan, like the one in Michigan, provides benefits to an injured person regardless of fault. All the state requests from the injured party is that he or she is honest in making the claim. Misrepresentation of material facts in the presentation of a no-fault claim is considered fraud and deprives the injured party of the right to receive benefits.
IN Mark Smith v. Michigan Automobile Insurance Placement Facility, a decision in the Michigan Court of Appeals, Smith lied to the Placement Facility when he made his claim and tried to avoid losing benefits by claiming that he forgot his previous condition and did not knowingly lie.
Smith visited his doctor, Dr. Mohamed Ayad, twice and complained of “chronic” and “acute” back and neck pain. Shortly afterwards, Smith was involved in a car accident that, according to Smith, injured his back, neck and shoulder. Smith then applied to the Michigan Automobile Insurance Placement Facility for personal protection insurance benefits (PIP). In this application, the plaintiff stated that he had no existing conditions and did not seek treatment for such conditions before the accident.
Smith falsely testified that he met Dr. Ayad before the accident, but only for general health checks. However, Smith’s medical records from Dr. Ayad showed that Smith visited Dr. Ayad for “chronic” and “acute” back and neck pain.
The insurer claimed that Smith committed fraud when he stated in his application that he did not have neck and back problems before the accident.
Smith, dissatisfied, sued and claimed that the insurer unreasonably and unlawfully neglected to award an insurer to pay Smith his requested PIP benefits.
A statement is essential if it is reasonably relevant to the insurer’s investigation of a claim.
You make a deliberately false statement when you know that the statement is false, or when the statement is made ruthlessly even without knowledge of the truth.
Smith complained of back and neck pain, which was characterized as “chronic” and “acute”, six months before he applied for benefits. He was given medication for this pain and did not state that he had stopped taking the medication before his application for a grant was submitted. Smith did not state in his deposit that he went to the doctor before the accident for neck and back pain, but had only forgotten when he applied for benefits – rather he only stated that he visited the doctor for regular check-ups and mild neck pain. from sleeping wrong.
Smith did not provide a confirmation or other evidence in response to the insurer’s claim in its summary disposition claim that Smith knowingly distorted information in his application. Smith provided no evidence of a pre-existing condition, let alone an exacerbation of that condition.
In fact, he initially denied having any significant back or neck pain prior to the accident. The alleged fraud was material because it was decisive as to whether his claim could be accepted, with or without an existing condition.
This case is a perfect example of the last ditch attempt by a criminal who claimed – after being accused of a violent crime – “I did not know the gun was loaded.”
He knew, he lied and his journals confirmed the lie. No one, not even in a car insurance state without fault, should be allowed to take advantage of a fraudulent claim. What the district court and the court of appeal should have done at the end of their decision is to refer Smith to a local prosecutor for a criminal insurance fraud. They did not, they were happy that he could not pick up.
(c) 2022 Barry Zalma & ClaimSchool, Inc.
Barry Zalma, Esq., CFE, now limits his internship 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 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. He is available at http://www.zalma.com and firstname.lastname@example.org.
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