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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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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The New Jersey Supreme Court ruled in favor of a national auto insurer which sought reimbursement from a third party after the insured was involved in a car accident. Law360 reported that GEICO was allowed to be reimbursed for medical expenses from the insurance company of a convenience store that was sued by a drunk driver who bought a bottle of vodka from the store and consumed it before getting behind the wheel.
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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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