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Zalma's insurance fraud letter – April 15, 2019



Insurance Fraud is Epidemic

The following was adapted from the Introduction to my book, "Insurance Fraud and Weapons to Defeat Insurance Fraud" which is available in two volumes as Kindle Book or a paperback from Amazon.com with Volume 1 Available as a Kindle book and a paperback and Volume Two Available as a Kindle book and a paperback.

Insurance fraud is expensive

Insurance fraud constantly takes more money each year than it did last from the insurance company. There is no certain number because most attempts at insurance fraud succeed. Estimates of the extent of US insurance fraud range from $ 87 billion to over $ 300 billion annually.

Read the full article here.

The Insurance Fraud Prevention Law generally gives the right to sub-offenses on the State of State

Illinois and California adopted an insurance fraud prevention law that allows the public to file on behalf of the state anti-fraud clothing. In the state of Illinois ex rel. David P. Leibowitz, manager of the bankruptcy estate of Marie A. Cahill against Family Vision Care, LLC, Novamed Management Service, LLC, Surgery Partners, Inc. and Jennifer Gula, No. 1

-18-0697, 2019, IL App (1st 180697 Illinois Court of Appeal First District Second Division (March 12, 2019) A bankruptcy trustee on behalf of the bankruptcy and the state filed an act of action against a caregiver accused of deceiving the public.

ISSUES

The Illinois Court of Appeal was asked to determine whether the State may assign damages to its sovereignty to a third party and (ii) whether the third party can derive from that loss of absenteeism to the State. Both questions were answered for the first time in Illinois.

The Court of First Instance found that the plaintiff, the trustee of Marie Cahill's bankruptcy estate, was not standing, since the state was only affected by its sovereignty, not an economic loss, and the State cannot harm a private citizen with its sovereignty. The court also found that the plaintiff was not an "interested person" under the law, as Cahill did not suffer an injury related claim and did not claim that the controversy decision would affect a claim or right for her.

ANALYSIS

The appeal court differed from the standing analysis of the trial. According to the law of the law and its purpose of combating insurance fraud, the state must not have suffered monetary damages in order to embark on a guardian in a quiam or whistleblower action. Furthermore, it is an "interested person" according to the charter and a person who has no personal injury to have standing.

The court in appeal agree with the trial that dismissal was not justified by the contract agreement or for not having claimed a claim. Thus, we partially confirm, reverse part, and prevent further processing.

Background

Family Vision Care, LLC, is an optometrist exercise in LaGrange, Illinois. NovaMed Management Service, LLC, a pharmaceutical management company, purchased Family Vision Care, LLC and merged with Surgery Partners, Inc. (Surgery Partners), a publicly traded company. Dr. Jennifer Gula is an optician at Family Vision Care, LLC, with no ownership in practice.

Cahill worked for Family Vision Care from October 2012 to January 2016. As an office administrator, Cahill handled insurance billing. According to Cahill, approximately 90 percent of Family Vision Care's income from claims on a visa service plan (VSP), a health insurance company, came.

VSP covers only claims from optometrists that have majority ownership and complete control of their medical practices. Cahill claims that Family Vision Care conducts fraud by deliberately and falsely certifying that they are eligible for VSP insurance and accept payments that they were not entitled to.

In February 2016, after Cahill left Family Vision Care, she signed a separation agreement and generally released "completely and unconditionally" freeing and emptying her employer from liability, claims and causes of action "arising out of or in connection with employee employment or separation from employment with the employer and all claims for documents or defective documents that occurred up to the time the employee signs this agreement. "
Cahill was filed for bankruptcy in January 2016. More than a year later, the trustee left of the estate (Estate) a single complaint against Family Vision Care for fraud leaves false claims to VSP, which is not a party. The record shows that David P. Leibowitz is the estate manager of the bankruptcy estate. Section 15a of the Act is a clause for enforcement that allows private whistleblowers with undiscovered information on insurance fraud to sue for civil penalties.

Family Vision Care submitted a combined decision to dismiss. The trial denied the Family Vision Care section 2-615 movement to find Cahill allegedly fraudulent behavior with sufficient specificity. The court also denied Family Vision Care's dismissal request based on the separation agreement, and there were actual questions about whether Cahill could have released the bankruptcy estate claim, as well as whether Cahill's claim falls during the release. In the case of standing dismissed the lawsuit complaint, that the property failed to claim or explain how it stands to claim the law. Note that the law does not define "interested person", the court decided that an applicant must have no legal interest in the action. Thus, the property was missing.
Furthermore, the trial stated that even if the property could receive a real action, the property did not consider "an injury" that the state could allocate.

The Act, which the Illinois General Assembly adopted in 2001, imposed civil penalties against existing criminal actions against fraud against private insurance companies. Relevant in this case, paragraph 5 (b), creates a private matter in action against any entity that violates the Illinois Criminal Code of Insurance Fraud. A person undertakes insurance fraud "when he or she obviously receives an attempt to obtain or cause to be subject to fraud, control of an insurance company's property *** by making a false claim or by invoking a false claim to make any insurance policy issued by an insurance company *** which intends to permanently deprive an insurance company or a self-insured entity of the right of use of that property. "720 ILCS 5 / 17-10.5 (a) (1)) (Vest 2016).

The Illinois Charter includes a provision on probation that allows private whistleblowers to obtain information on insurance fraud to sue for civil penalties. An interested person, including an insurer, may bring civil action for violation of this law for the person and the state of Illinois.

A plaintiff does not have to claim facts about establishing standing. Wexler v. Wirtz Corp., 211 Ill. 2d 18, 22 (2004). Rather, the defendant is incumbent on bending and proving lack of standing.
By definition, the ruling means that claims from individual parties to help the executive department in the enforcement of the law, whose violation affects the government's interest, not the individual relation, whose only motivation to carry a suit is to regain some of the measure according to law. Of course, the state suffers damage to its sovereignty when its laws are violated. Standing in legal proceedings under the False Claims Act has been raised by the Illinois Supreme Court in Scachitti against UBS Financial Services, 215 Ill. 2d 484, 508 (2005), where the court acknowledged that in another case there is no cognizable damage that actually suffered from the relatives. The Supreme Court of Illinois argued that a claim for a claim is a partial task of the state's law under the law, allowing an individual to bring a civil action for violation of the law of the person and the state.

The property claims that the law, like the False Claims Act, allows a relative to bring civil actions to the person and the state of Illinois.

The law's simple language and its purpose supports a finding that the state does not have to suffer monetary damages to go to a relator.

Family Vision Care's view to allow a citizen to sue on behalf of the state opens the proverbial floods to litigants who seek a statement that a fee is without merit. A plaintiff can only bring a claim if (i) the state authorizes the relatives to sue on behalf of the state and the relationship and (ii) the state retains control over the disputes. The law requires both. Furthermore, for the law – a statute designed to deter insurance fraud – for effect, witnesses in any fraudulent insurance claims, such as Cahill, must be able to complain.

The Charter lacks the definition of the term "Interested Person", so the Court must enforce the legislature's intention and give its statutory language its usual, common and popular meaning. Looking at the common language of § 15 a) in light of other provisions of the Charter and the Charter of Purpose, reveals that "interested person" includes whistleblowers such as Cahill. To allow whistleblowers, as Cahill, who has evidence of possible fraud, to further develop the law's purpose to protect the public from insurance fraud. Statutes must be interpreted with regard to the "cause of the law, the problems being tried, the aims to be achieved, and the consequences of interpreting the charter in one way or another. The goals of the law include harmless illegal gain, repayment, state compensation for costs. For investigation and prosecution and alleviate the social costs of increased insurance interest rates due to fraud, state parties who have information on possible insurance fraud to claim on behalf of the state meet these objectives.

A California Appeal Court Applying a Statute Identical to Illinois The Charter held it as a proper question, insurance code section 1871.7 does not authorize the relatives to have suffered their own damage. The court further stated that the trial under section 1871.7 was based on an injury allegedly suffered by the people of the state of California and was not filed for the purpose of remedying damage as a leader n agate
In this context, an employee like Cahill is an "interested person" because she has non-public information about possible inaccuracies and as a whistleblower does not have to suffer personal injury.

Although Cahill is an interested person because of her whistleblower status, Family Vision Care claims that the estate does not have significant information about potential errors in Family Vision Care, just Cahill. However, when a bankruptcy action has been initiated, all unpaid trials become part of the bankruptcy estate and only the bankruptcy administrator has the power to run them.

In addition, the state is the real party in the interest and a registrar on behalf of the State cannot waive the state's requirements. As a result, the Court of Appeal confirmed the court's decision not to reject.

APPLICATION OF PLEADINGS

Rejection requires that no facts be found that enable the plaintiff to recover. Fraud must be claimed with sufficient specificity, specificity and security to encourage the other party to answer. A plaintiff must assert himself with specificity and specificity, facts from which fraud is necessary or probable inference, including erroneous information, when made, who made them and to whom they were made.

The alleged mining designation Dr. Yellow VSP supplier agreement since 2014 and certified that she had majority ownership in Family Vision Care and fulfilled VSP's claim for insurance compensation. The property attached a copy of a supplier agreement as an exhibition with Dr. Gula's signature. The complaint also claimed Family Vision Care was familiar with VSP's ownership, but under the guidance of Surgery Partners, Dr. Yellow and Family Vision Care to make false representations to VSP throughout Surgery Partner's ownership of Family Vision Care. And that Frank Soppy, a vice president at Surgery Partners, instructed Cahill to tell VSP that Family Vision Care was a single proprietorship owned by Dr. Yellow. These claims meet the heightened standard of common law fraud and relate to what, when and who of Family Vision Care's distortions.

ZIFL OPINION

Since Illinois and California appear to be the only states with this statute insurer having evidence that they have been deceived by an insured, by a service provider such as Family Vision, of a body deal, by a group of chiropractors, a group of lawyers or other professionals who claim they are trying to insure the insurer to stop the fraud. These statutes – given that insurance fraud is unfortunate in both Illinois and California, I find this a method of defeating insurance fraud, as many prosecutors are lurking in prosecuting insurance fraud.


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Zalma on the insurance blog has written over 2550 digests of decisions on insurance decisions and other important insurance materials and articles published five days or more a week and is available at http: //zalma.com/blog[19659037]

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