Justia Insurance Law Opinion Summaries

Following a preliminary hearing, petitioner Dr. Sanjoy Banerjee was charged in an information with two counts of presenting a false or fraudulent health care claim to an insurer (a form of insurance fraud, counts 1-2), and three counts of perjury (counts 3-5). The superior court denied Banerjee’s motion to dismiss the information as unsupported by reasonable or probable cause. Banerjee petitioned for a writ of prohibition to direct the superior court to vacate its order denying his Penal Code section 995 motion and to issue an order setting aside the information. The Court of Appeal issued an order to show cause and an order staying further proceedings on the information, pending the Court's resolution of the merits of Banerjee’s petition. The State filed a return, and Banerjee filed a traverse. The State argued the evidence supported a strong suspicion that Banerjee committed two counts of insurance fraud and three counts of perjury, based on his violations of Labor Code section 139.3(a) between 2014 and 2016. During that period, Banerjee billed a workers’ compensation insurer for services he rendered to patients through his professional corporation and through two other legal entities he owned and controlled. The insurance fraud charges are based on Banerjee’s 2014-2016 billings to the insurer through the two other entities. The perjury charges were based on three instances in which Banerjee signed doctor’s reports, certifying under penalty of perjury that he had not violated “section 139.3.” Banerjee argued: (1) the evidence showed he did not violate the statute's referral prohibition; (2) even if he did not comply with section 139.3(e), the “physician’s office” exception to the referral prohibition applied to all of his referrals to his two other legal entities; and (3) the patient disclosure requirement of section 139.3(e), the referral prohibition of section 139.3(a), and the physician’s office exception to the referral prohibition were unconstitutionally vague. The Court of Appeal concluded: (1) Banerjee did not violate section 139.3(a) by referring his patients to his two other legal entities; and (2) the evidence supported a strong suspicion that Banerjee specifically intended to present false and fraudulent claims for health care benefits, in violation of Penal Code section 550(a)(6), by billing the workers’ compensation insurer substantially higher amounts through his two other legal entities than he previously and customarily billed the insurer for the same services he formerly rendered through his professional corporation and his former group practice. Thus, the Court granted the writ as to the perjury charges but denied it as to the insurance fraud charges. View "Banerjee v. Super. Ct." on Justia Law

On February 22, a criminal complaint was filed against the defendant for unlawful driving or taking of a vehicle. On February 26, the defendant was in custody and present in court for a pretrial hearing. The court continued the matter to March 20. The Surety posted a bond of $25,000 for the defendant’s release from custody. At the March 20 pretrial hearing, the defendant was not present. The court told defense counsel “I’ll give you a week to bring him back in. … Bench warrant of 35,000 held … it’s not likely to waste your family and friends money and then FTA on a 10851.” On March 28, the defendant again failed to appear. The court ordered bail forfeited. A notice of forfeiture was mailed to the parties on March 29.On October 2, the Surety moved to vacate, forfeit, and exonerate bail or to extend time, arguing that the court lost jurisdiction over the bond because it failed to declare a forfeiture (Penal Code 13051) when the defendant did not appear on March 20. The court of appeal affirmed the denial of the motion. The trial court had a rational basis for believing there may have been an excuse for the defendant’s failure to appear sufficient to warrant continuing the case without declaring a forfeiture and retained jurisdiction to later declare the bail forfeited. View "People v. Bankers Insurance Co." on Justia Law

Defendant Daniel Clapp plead no contest to concealing the true extent of his physical activities and abilities from his employer, the Department of the California Highway Patrol (CHP), and the State Compensation Insurance Fund (SCIF). Consistent with a resolution negotiated by the parties, the trial court granted defendant three years’ probation, and as a condition of probation, ordered him to pay restitution. Following a hearing, defendant was ordered to pay $30,095.68 to SCIF for temporary disability benefits and $81,768.01 to CHP for benefits wrongfully obtained. He was also ordered to pay $1,350 and $70,159 to SCIF and CHP respectively for investigative costs. Defendant appealed the restitution award as to investigation costs contending that, as public investigative agencies, neither SCIF nor CHP was entitled to reimbursement for the costs of investigating his claim. After review, the Court of Appeal concluded that as direct victims of defendant’s fraud, both CHP and SCIF were indeed entitled to restitution for investigative costs incurred in an effort to justify discontinuance of payments and recoup money defendant fraudulently obtained. View "California v. Clapp" on Justia Law

Petitioner Andrew Panaggio appealed a New Hampshire Compensation Appeals Board (Board) determination that respondent, CNA Insurance Company (the insurer), could not be ordered to reimburse him for his purchase of medical marijuana because such reimbursement would have constituted aiding and abetting his commission of a federal crime under the federal Controlled Substances Act (CSA). When Panaggio appealed the insurer’s denial to the New Hampshire Department of Labor, a hearing officer agreed with the insurer. Panaggio appealed the hearing officer’s decision to the Board, which unanimously found that his use of medical marijuana was reasonable and medically necessary. Nonetheless, the Board upheld the insurer’s refusal to reimburse Panaggio, concluding that “the carrier is not able to provide medical marijuana because such reimbursement is not legal under state or federal law.” The New Hampshire Supreme Court surmised the issue on appeal raised a question of federal preemption, "which is essentially a matter of statutory interpretation and construction." Although it was an issue of first impression for the New Hampshire Court, other courts considered whether the CSA preempted a state order requiring reimbursement of an employee’s purchase of medical marijuana. Panaggio reasoned that “[b]ecause New Hampshire law unambiguously requires the insurer to pay for the claimant’s medically related treatment,” an insurer that reimburses a claimant for the purchase of medical marijuana acts without the volition required by the federal aiding and abetting statute. The insurer asserted Panaggio’s argument leads to an absurd result, observing that “[c]onflict preemption applies because state law requires what federal law forbids.” The New Hampshire Supreme Court ultimately concluded the CSA did not make it illegal for an insurer to reimburse an employee for his or her purchase of medical marijuana. "[A] Board order to reimburse Panaggio does not interfere with the federal government’s ability to enforce the CSA. Regardless of whether the insurer is ordered to reimburse Panaggio for his medical marijuana purchase, the federal government is free to prosecute him for simple possession of marijuana under the CSA." Under these circumstances, the Court concluded the “high threshold” for preemption “is not met here.” The Board's decision was reversed and the matter remanded for further proceedings. View "Appeal of Andrew Panaggio" on Justia Law

Defendant was charged with driving under the influence of alcohol and obtained a $35,000 bond for his release from custody. The surety promised to assure Defendant’s appearance for arraignment. The contract stated that, if Defendant left the jurisdiction, he would “voluntarily return” and “waive extradition.” On the day of the arraignment, Defendant's indemnitor informed the surety Defendant told her he was in Mexico. The court forfeited the bail bond. Under Penal Code 1305(c), the court was required to vacate the forfeiture if Defendant appeared in court, either voluntarily or in custody, within 180 days. The court extended the appearance period by six months. The surety then moved to vacate the forfeiture and exonerate the bond or to toll or extend time, arguing that Defendant was located in Mexico and “subject to “constructive custody,” having obtained a Mexican passport and applied for a U.S. visa. The surety contended the People were imposing improper conditions, including a requirement that the surety pay for extradition ($50,000). The surety argued Defendant was in effect detained as a result of immigration laws that precluded his reentry. The People argued they could not extradite Defendant on a misdemeanor charge and that he was not detained but left the country voluntarily. The court of appeal affirmed summary judgment against the surety, rejecting an argument that Defendant suffered from a “temporary disability” under Penal Code 1305(e), View "People v. The North River Insurance Co." on Justia Law

Allstate filed suit under Insurance Code section 1871.7 on behalf of the People against defendant, her mother, and others for insurance fraud in violation of Penal Code section 550, which makes it unlawful to submit false or fraudulent claims to an insurance company. The jury found in favor of Allstate.The Court of Appeal affirmed, holding that the trial court did not abuse its discretion in denying defendant's ex parte application for a stay. The court also held that unlawful conduct under section 550 does not require a misstatement of fact in the insurance claim. In this case, defendant and her mother committed insurance fraud in violation of section 550 where they perpetrated a deceitful insurance scheme designed to acquire insurance proceeds illegally for personal gain. View "People ex rel. Allstate Insurance Co. v. Suh" on Justia Law

Javonne Hunt appealed a district court order requiring him to pay $27,501.86 in restitution to Blue Cross Blue Shield (“BCBS”). In 2017, Hunt was playing basketball at the YMCA in Bismarck, North Dakota when he was involved in an altercation with an opposing player. Hunt intentionally struck the opposing player in the jaw causing a bone fracture. Hunt was charged and subsequently found guilty by a jury of aggravated assault. Following his conviction, Hunt agreed to pay as restitution the out-of-pocket medical expenses incurred by the injured individual in the amount of $3,233.07. BCBS provided evidence that it had paid an additional $27,501.86 for the medical treatment of the injured individual under the injured individual’s policy of insurance. The district court applied N.D.C.C. 12.1-32-08(1) in granting restitution to BCBS and ordered Hunt to pay a total of $30,734.93; $3,233.07 for the conceded out-of-pocket costs plus the $27,501.86 claimed by BCBS. Hunt argued BCBS is precluded from recovery of its expenditures in the criminal proceedings because the definition of “victim” under N.D. Const. art. I, section 25 was incompatible with a recovery by a corporation under the criminal restitution statute, N.D.C.C. 12.1-32-08(1). The North Dakota Supreme Court found no reversible error in the district court’s judgment and affirmed the order. View "North Dakota v. Hunt" on Justia Law

In an earlier appeal, Indiana Lumbermens Mutual Insurance Company (Lumbermens) challenged an order denying its motion to vacate summary judgment on a bail bond forfeiture and to exonerate the bail bond. The day after Lumbermens filed its notice of appeal, American Surety Company (American), the appellant here, filed an undertaking to stay enforcement of the summary judgment during the first appeal. In an unpublished opinion, the Court of Appeal affirmed the order denying Lumbermens’ motion to vacate the summary judgment and to exonerate the bail bond. Six days before the Court of Appeal issued the remittitur in the first appeal, American filed a motion in the trial court to exonerate the undertaking and to be released from liability on the undertaking. The undertaking was filed pursuant to Code of Civil Procedure section 917.1; because Lumbermens’ appeal was from a postjudgment order denying a motion to vacate the summary judgment, which was not a money judgment or an order directing the payment of money, American argued section 917.1 did not apply, and the undertaking was ineffective at all times. The trial court denied the motion, concluding American forfeited its challenge to the validity of the undertaking by waiting to file its motion until 57 days after the Appeals Court issued its opinion in the first appeal, and six days before the remittitur. In this case, American renewed its argument the undertaking it filed on behalf of Lumbermens was ineffective because Lumbermens appealed from a postjudgment order, and not from the summary judgment itself and, therefore, the stay provided for in section 917.1 was never triggered. In addition, American argued the undertaking never became effective because the trial court did not approve it as required by statute. The Court of Appeal determined American was correct that the undertaking it filed in the first appeal was never effective. Likewise, American was correct that, even if section 917.1 applied to Lumbermens’ appeal, the undertaking was not effective because the trial court did not approve of it pursuant to section 995.840 (a). Nonetheless, the Court agreed with the State that American forfeited its challenge to the validity of the undertaking by waiting until six days before the issuance of the remittitur to file its motion to vacate the undertaking. And, even if the Court concluded American did not forfeit its challenges to the undertaking, the Court agreed with the State that American was estopped from challenging the undertaking on appeal. View "California v. American Surety Co." on Justia Law

A jury convicted former United States Postal Service employee Robert Hamilton of three counts of making a false or fraudulent statement for the purpose of obtaining compensation under the California workers' compensation law. On appeal, Hamilton argued: (1) because, as a federal employee, his workers' compensation benefits were provided under the Federal Employment Compensation Act, the doctrine of federal preemption barred him from being prosecuted under California law for any offense alleging fraud in obtaining federal workers' compensation benefits under FECA; and (2) regardless of whether the prosecution was preempted, his conviction was supported by insufficient evidence under Insurance Code section 1871.4 (a)(1) because that statute applied only to false or fraudulent statements made for the purpose of obtaining compensation afforded under the California workers' compensation law, which was not applicable to him as a federal employee. On the issue of federal preemption, the Court of Appeal concluded that Hamilton did not meet his burden to establish that the State's prosecution of him was preempted. With respect to the sufficiency of the evidence, the Court agreed with the State's concession that insufficient evidence supported Hamilton's convictions because he did not receive compensation under the California workers' compensation law. The Court declined to exercise discretion to modify the judgment to impose convictions on a lesser included offense. Accordingly, the judgment was reversed. View "California v. Hamilton" on Justia Law

In 2010, the defendants formed PremierTox, a urinalysis testing company: Doctors Peavler and Wood owned a substance abuse treatment company, SelfRefind; Doctor Bertram previously worked for SelfRefind. Bottom and Walters owned a drug testing service and laboratory. Physicians at clinics ordered urinalysis tests to check if their patients used illicit drugs and to monitor their medications. PremierTox was to receive those urine samples, perform the testing, and report back. In October 2010, SelfRefind began to send frozen urine samples to PremierTox for testing, but PremierTox did not have the correct equipment. In 2011, after PremierTox bought the necessary, expensive machines, they broke down. Urine samples from SelfRefind piled up. PremierTox started testing them between February and April 2011 and finished testing them in October. Over the same period, it tested and billed for fresh samples as they came in, aiming for a 48-hour turnaround. PremierTox billed insurers, saying nothing about the delays. The defendants were charged with 99 counts of health care fraud and with conspiracy. A jury acquitted them of conspiracy and 82 of the health care fraud charges and convicted them of 17 health care fraud charges. The trial judge imposed sentences of 13-21 months in prison. The Sixth Circuit affirmed the convictions. A reasonable jury could find that the defendants violated 18 U.S.C. 1347 by requesting reimbursement for tests that were not medically necessary. View "United States v. Walters" on Justia Law