Justia Insurance Law Opinion Summaries

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 In an unpublished opinion, the Court of Appeal affirmed the order denying Lumbermens’ motion to vacate the summary judgment and to exonerate the bail bond.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

Third-party defendant Dr. George Likakis was charged with aggravated arson and insurance fraud after a fire destroyed a building he owned (the Property). Plaintiff RSI Bank held a first-priority mortgage on the Property, and defendant/third-party plaintiff The Providence Mutual Fire Insurance Company (Providence) issued a commercial liability policy that covered the Property. Following the fire, Likakis and RSI Bank submitted insurance claims. Providence denied both sets of claims. Providence’s denial of coverage prompted the filing of two actions in the Law Division: (1) filed by Likakis against Providence; and (2) an action gave rise to this appeal: RSI Bank’s claims against Providence for breach of contract, fraudulent misrepresentation, violations of the Consumer Fraud Act, and bad faith. Providence filed a third-party complaint against Likakis, alleging claims for indemnification. Both civil lawsuits were pending when criminal proceedings commenced against Likakis. Likakis was indicted; Providence did not object to Likakis’ admission to the PTI program, provided he paid restitution, committed to protect/compensate Providence from all claims that might be brought by RSI, and dismissal of Likakis’ suit against Providence. With Likakis’s consent - but no assessment of his ability to pay - the court also imposed the three conditions that Providence had requested. During his PTI term, Likakis paid Providence the specific restitution amount and dismissed with prejudice his lawsuit. Likakis did not make any payment related to the separate indemnification provision. With the prosecutor’s consent, the PTI court terminated Likakis’s PTI supervision and dismissed his indictment. RSI Bank and Providence settled their coverage dispute. Providence agreed to pay RSI Bank to settle all of the bank’s claims based on the insurance policy and moved for summary judgment against Likakis based on the provision of the PTI agreement. The court held that the indemnification provision of the PTI agreement was enforceable against Likakis and ordered Likakis to pay Providence the portion of the settlement funds Providence attributed to fire damage, less the amount Likakis had paid during his PTI supervisory period. Likakis appealed, and an Appellate Division panel affirmed. The New Jersey Supreme Court reversed, finding an open-ended agreement to indemnify the victim of the participant’s alleged offense for unspecified future losses was not an appropriate condition of PTI. Moreover, a restitution condition of PTI was inadmissible as evidence in a subsequent civil proceeding against the PTI participant. The indemnification provision of the PTI agreement at issue should have played no role in this civil litigation. View "RSI Bank v. The Providence Mutual Fire Insurance Company" on Justia Law

From 2006-2012 Packerland deceived at least one of its customers about the protein content of its Whey Protein Concentrate. Land O’Lakes purchased Packerland’s protein concentrate for use in making foods for calves and other young animals. Buyers infer protein levels from measuring nitrogen: a seller can add another nitrogen-rich substance to produce higher scores. The Ratajczaks, who owned Packerland, started adding urea to its protein concentrate. in 2006. Land O’Lakes suspected that the concentrate was high in nonprotein nitrogen but could not learn why; the Ratajczaks made excuses that Land O’Lakes accepted. The Ratajczaks sold Packerland in 2012. The new owner kept them as employees; they kept adding urea until the buyer learned what the truth. The Ratajczaks lost their jobs and settled for about $10 million before the buyer filed a complaint. Land O’Lakes stopped buying Packerland’s product and asserted claims of breach of contract, fraud, and violation of the Racketeer Influenced and Corrupt Organizations Act. Packerland’s insurers refused to defend or indemnify it or the Ratajczaks; the Ratajczaks’ personal insurer refused to indemnify them for their settlement with Packerland’s buyer. The district court dismissed Land O’Lakes’s suit and ruled in favor of the insurers. The Seventh Circuit affirmed, rejecting Land O’Lakes’ claim to treble damages under RICO and state-law and the Ratajczaks’ claims that Packerland’s insurers and their own insurers had to defend and indemnify them. View "Land O'Lakes, Inc. v. Ratajczak" on Justia Law

In December 2009, defendant Randell Blake was convicted of filing a false insurance claim in connection with a 2007 fire at his house. Subsequent to his criminal convictions, the trial court ordered defendant to pay restitution to his insurer, Safeco Insurance Company of America (Safeco). Defendant appealed the trial court’s restitution order, arguing the order should be vacated because a general release, signed by Safeco in a related civil case, relieved him of any duty to pay it restitution. He also argued the order should be vacated because the trial court failed to make findings regarding his ability to pay restitution. The Vermont Supreme Court found that restitution and civil damages originated within separate systems, were not substitutes for each other; a civil court’s award of damages to a plaintiff did not discharge the criminal court’s duty or authority to consider and order restitution. Therefore, a civil settlement or release cannot entirely preclude a criminal restitution order because: (1) the statutory obligation to impose restitution when necessary leaves no room for private parties to preclude a court from ordering it; (2) a release does not address the underlying purposes of restitution; and (3) the victim has no standing and is not a party in the restitution proceeding, and may seek a separate remedy in an action for civil damages. Here, defendant initiated a civil suit against Safeco for payment he claimed it owed him relating to the house fire and Safeco counterclaimed. The exchange of releases extinguished these competing civil claims. The release Safeco signed did not, however, preclude an order of restitution in the related criminal proceeding. The Supreme Court therefore affirmed the trial court’s determination on this matter; but reversed because the trial court by not considering his ability to pay. View "Vermont v. Blake" on Justia Law

An entity engaged in the bail bond business may not retain the premium paid on a criminal defendant’s behalf when bail is denied and the defendant is never released from custody.Arthur Bogoraz was indicted on state law fraud charges. Plaintiffs, Bogoraz’s wife and family friends, entered into an indemnity agreement with Ira Judelson, a licensed bail bond agent affiliated with the International Fidelity Insurance Agency, to secure Bogoraz’s release from custody in exchange for a premium of $120,560. The district court denied the bail bond after a hearing, however, and Bogoraz was never released from custody. Judelson refused to return the $120,560 to Plaintiffs. The district court found that the indemnity agreement permitted Judelson to retain the premium. On appeal, the United States Court of Appeals for the Second Circuit certified a question of law regarding the issue to the Court of Appeals. The Court of Appeals held that, under the Insurance Law, an entity engaged in the bail bond business does not earn a premium for a bail bond if a court refuses to accept the bond following a bail source hearing and the principal is not released on bail. View "Gevorkyan v. Judelson" on Justia Law

Defendant-appellant John Riddles pled guilty to one count of workers' compensation insurance fraud. His conviction grew out of his application for workers' compensation insurance, which fraudulently represented that a number of nurses who had been placed in residential care and skilled-nursing facilities by Riddles' staffing agency were computer programmers. His misrepresentation of the nurses as computer programmers substantially reduced the premium his agency was charged by the workers' compensation insurer that accepted his company's application; accordingly, the trial court required that Riddles pay, as restitution to the insurer, $37,000 in premiums the insurer would have earned in the absence of his misrepresentation. Contrary to his argument on appeal, a workers' compensation insurer could recover, as restitution under Penal Code section 1202.4, the premiums it would have earned in the absence of misrepresentations by an insurance applicant. The fact Riddles may have been able to establish that the Labor Code did not require that he provide workers' compensation coverage for the nurses did not relieve him of responsibility for providing the insurer with a fraudulent application or alter the fact the nurses were covered by the policy he obtained. View "California v. Riddles" on Justia Law

Kielar, a pharmacist, got many patients from Dr. Barros, whose office was in the same building, and began defrauding two insurance companies. Kielar forged prescriptions for Procrit under Barros’s name and submitted them for payment, knowing that Procrit had neither been prescribed, nor provided, to the individuals under whose policies he sought reimbursement. The insurers lost $1,678,549. Kielar was indicted for health care fraud, 18 U.S.C. 1347, with a forfeiture allegation, 18 U.S.C. 982(a)(7) that identified properties subject to forfeiture, including a Florida property. Kielar asserted that he needed the proceeds of its sale to pay legal fees. The court granted a motion to release lis pendens and ordered that the proceeds of the sale be placed in escrow with the U.S. Marshals Service. Kielar unsuccessfully requested that the court allow him to use the sale proceeds “for taxes, legal fees and other expenses.” He was convicted of six counts of health care fraud; three counts of aggravated identify theft, 18 U.S.C. 1028A(a)(1); and of using false records to impede a federal investigation, 18 U.S.C. 1519. The Seventh Circuit affirmed, rejecting arguments that the court erred in failing to hold a hearing on his request to release his escrowed funds, by limiting cross-examination of Barros, and by preventing Kielar from calling a former patient as a defense witness. View "United States v. Kielar" on Justia Law