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Star Casualty Insurance Company appealed the final judgment and attorney’s fees awarded in favor of Gables Insurance Recovery, Inc., as the employee of Star Casualty Insurance Company, Ana Maria Correa. Star Casualty contends that the trial court erred in granting summary judgment on factual issues regarding whether Correa’s medical expenses for diagnostic procedures were medically necessary and related to the accident pursuant to section 627.736, Florida Statutes. In addition, Star Casualty argued that the trial court erred in granting four affirmative responses to the amended answer, which would have allowed them to remain liable for the claims.
In Star Casualty Insurance Company v. Gables Insurance Recovery, Inc., a/a/o Ana Maria Correa, Nos. 3D21-0033, 3D21-0377, Florida Court of Appeals, Third District (July 20, 2022) The Court of Appeals was faced with an attempt to avoid the consequences of an arrest for fraud unless the plaintiff vacates the judgment. saying and denying all the claims were true.
Correa was involved in a car accident on January 19, 2009 and was injured. Subsequently, Correa received diagnostic procedures that cost a total of $3,375.00, and Gables, as his employer, filed a claim against the insurer to reimburse him eighty percent of the cost of the appropriate medical treatment pursuant to section 627.736 (1) (a). After the insurer paid only $400.71 and denied the rest, Gables sued for the rest of the money.
Star Casualty filed an affidavit with Edward A. Dauer, MD, stating that the charges were not medically necessary or related to the accident. The affidavit also noted that three of the recording procedures performed on Correa appear to have been improperly modified or inconsistent with other procedures.
Based on the confirmation of Dr. Dauer, Star Casualty amended its answer to add a defense asserting that it did not pay the full amount because the three claims were fraudulent, retained, or excluded. Prior to the ruling, Gables voluntarily recused himself from the three lawsuits filed by Star Casualty in his defense. Gables then moved to strike the defense from Star Casualty’s answer, arguing that the exclusion of the claims in the three cases would render the common defense ineffective and confusing.
The trial court granted summary judgment on the merits issue and granted Gables’ motion to grant immunity on the ground that plaintiff had waived part of the alleged fraud.
The Court of Appeal stated that the court erred in finding that Dr. Dauer didn’t make a real story of things. A factual issue is “true” for purposes of summary judgment where a competent jury could rule in favor of the nonmoving party. A factual dispute is “material” when it would affect the outcome of the case under statutory law.
The only basis that Star Casualty has stated for a factual dispute regarding their importance is based on the information of Dr. Duration. In an official statement, Dr. Dauer said that the images that were taken “were not clinically relevant and are not related to the accident of 1 / 19 / 2009” because “there were no real investigations and documents that should have ordered x-rays in this case.” Because these findings created a genuine issue of necessity, the Court of Appeals determined that the summary judgment should be reversed and remanded.
After remand, the trial court that granted Star Casualty’s defense was reversed, as the defense was inconsistent with his complaint. An affirmative defense may not be struck out merely because it appears to the judge that the defendant is unable to provide evidence at trial to support such a defense.
The Supreme Court held that the case was only postponed because the defense case was voluntarily dismissed. In contrast, Star Casualty argues that because the defense alleged fraud, code retention, and inconsistency, such defenses were on the remaining charges.
Any insurance fraud voids all coverage. arising out of a claim related to such fraud under the defense of the insured who committed the fraud, regardless of whether any part of the insured’s claim may be valid.
The insurer is not required to pay interest or charges that are retained, or that are not included when the treatment or services are to be retained and Florida law allows both the insured and the insured not to pay any person who has provided willfully or falsely. misleading statements regarding claims or charges.
Evidence of insurance fraud required summary judgment in favor of the insured for the entire PIP claim with two separate claims for medical care and lost wages, since allowing payment of only one portion of the claim would allow the insured to take action. -value analysis considering such fraud.
A party seeking insurance money is no less fraudulent than a partially dead party. When caught in a fraud, as an expert witness, the fraud attempt cannot be ignored by simply removing it from what he said because the insurance, by proving another fraud, will convince the examiner that the claim was a fraud or an attempted fraud. interfered with the right to benefit from the policy. Trying to cheat, big or small; whether it relates to one part of the claim or another.
Standard Opinions on Insurance Volume XIV: Collection of Blog Posts from Zalma on Insurance –
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Barry Zalma, Esq., CFE, now limits his practice to working as an insurance consultant specializing in insurance coverage, insurance litigation, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He has practiced law in California for over 44 years as an insurance and claims attorney and over 54 years in the insurance business. He can be reached at email@example.com.
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