The owner of a window tinting business in Rockland County, New York, and his wife were arrested for allegedly defrauding the state Workers’ Compensation system after his wife took out a customer’s car on a joyride, getting into an accident, then claiming the crash happened while she was working. Continue reading “IG: Husband and Wife Fraudulently Collected Workers’ Compensation Benefits After Smashing Customer’s Car”
Tag: insurance coverage disputes
Court of Appeals Rules: Specific Contract Language Governs Reinsurance Liability Cap
The issue that has recently plagued the insurance world is the question of whether New York State law requires in its insurance contracts a rule of construction or presumption regarding the contract’s liability limitations and caps on the reinsurance available to cover defense costs. Continue reading “Court of Appeals Rules: Specific Contract Language Governs Reinsurance Liability Cap”
Nassau Supreme Court Hears Case Regarding “Necessary Emergency Health Services”
The Nassau Supreme Court case involved an individual injured in an accident in which their blood-alcohol content was .15%. The toxicology report taken by the hospital also showed the individual had THC in her system at the time of admission to the hospital room. The Hospital submitted a bill for hospital services to the insurer in the amount of $43,212.59. After learning of the toxicology report, the insurer requested verification in the form of a breakdown of which hospital services constituted emergency health services.
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Fraudulent Insurance Claims Revealed by Social Media
When defending against insurance claims in 2017, there are various forms of technology available to discover fraudulent claims. Through data analytics, internet-enabled automobiles, wearables and other forms of technology, insurance providers are able to discover when a claim is fraudulent. But what investigators are now starting to discover is that a claimant’s social media account could be the first place to start. Through a thorough investigation, a defendant can find valuable information to the defense of a claim. Recently, several claims have highlighted this fact.
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New York Court of Appeals Recognizes Difficulty of Interpreting Insurance Policies
In early 2016, the New York Court of Appeals heard the case of Selective Ins. Co. of America v. County of Rensselaer, 26 NY3d 649 (2016). The case involved a dispute over the language of an insurance policy between the insurer and the County of Rensselear. After settling a civil class action for the county, the insurer argued that each class member was subject to a separate deductible, while the county argued that there should only be one deductible applied to the class.
Insurance Fee Schedule Used as an Affirmative Defense
Submitting claims to insurance agencies can be complex as there are fee schedules and set services which are covered. One recent case involved fee schedules and payment of claims. Ms. Kenia Perez was a patient at East Coast Acupuncture (ECA) during August, September, and October 2013. After ECA submitted claims for Ms. Perez for treatments received, the defendant, Hereford Insurance Company, recalculated the amount of the claims based on their fee schedule. Afterwards, ECA brought suit to recover the amount of claims left unpaid by Hereford.
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