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Fraud Insurance Claims

Fraud is the making of false representations or engaging in deceptive behavior in order to unlawfully secure financial or personal gain. 
J.S. Held

Fidelity Investigations: A Comprehensive Guide to Successful Claims Outcomes – Second Edition

J.S. Held on

Introduction: Understanding Fidelity Investigations - Fidelity / Crime / Financial Institution Bonds, in a general sense, cover an insured from the willful theft of property, money, and securities by one of their employees...more

Davis Wright Tremaine LLP

Anthem's New Chargemaster-Based Claim Edits: Which Charges and Providers Will Anthem's New Process Target and How Will It Impact...

Effective August 1, 2025, Anthem will implement a new claims-editing process that adjusts payments for Medicare Advantage (MA) claims based on an undisclosed, customized chargemaster table. The announcement identifies claims...more

Stevens & Lee

New Changes to Medicare and Private Prior Authorization Processes

Stevens & Lee on

Both the Centers for Medicare & Medicaid Services (CMS) and dozens of the nation’s largest insurance companies have revealed upcoming changes to their prior authorization processes. These changes aim to reduce the prevalence...more

Zelle  LLP

Court Grants Insurer’s Motion for Summary Judgment on Nearly All of Insureds’ Causes of Action

Zelle LLP on

Schnatzmeyer v. State Farm Ins. Co., No. 3:23-CV-02820-K, 2025 WL 1697505, at *1 (N.D. Tex. June 17, 2025). In a case involving two overlapping freeze claims—and a substantial array of legal issues affecting insurers in...more

JUSTICENTER

How Long Is an Insurance Check Good For?

JUSTICENTER on

If you’ve received a settlement check from an insurance company after a car accident, property damage claim, or injury settlement, you might be wondering: how long is an insurance check good for? While holding onto it for a...more

Carlton Fields

Iowa Supreme Court Reaffirms Rule That Faulty Workmanship Is Not an Occurrence, Leaving Question of Statutory Fraud for Another...

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In Dostart v. Columbia Insurance Group, the Iowa Supreme Court reaffirmed the rule — in Iowa, and many other jurisdictions — that faulty workmanship by a contractor does not constitute an “occurrence” as defined in a standard...more

Potomac Law Group, PLLC

Cybercriminals Hit Your Inbox—Now What? Recovering Funds After Business Email Compromise and Fraud Schemes

The global cyber scam industry is a multi-billion dollar racket run by crime syndicates who often operate through massive compounds known as “scam farms” in far flung locations.  On our shores, many businesses fall prey to...more

Zelle  LLP

N.M. Cyber Ruling Will Spur Litigation As Coverage Remedy

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A June 16 appellate decision involving the construction of a cyberinsurance policy demonstrates a concerning lack of judicial understanding about the nature and scope of cyber liability coverage and implicitly incentivizes...more

Wiley Rein LLP

For the Record: Cyber Coverage “For” a Security Breach is Ambiguous under New Mexico Law

Wiley Rein LLP on

The New Mexico Court of Appeals has held that cyber policy language affording coverage “for” a security breach was ambiguous and must be construed broadly to provide coverage for a breach of contract claim “because of,”...more

Zelle  LLP

Invoking ‘Our Option’ and Preferred Contractor Network Endorsements

Zelle LLP on

Increasing abuses in the claims process have caused insurance companies to rethink the traditional model of sending out cash to pay claims. Far too often, that cash is used for purposes other than fixing damage, with a...more

Wiley Rein LLP

No Second Bite at the Apple: New Emails Can’t Undo a False Application Response

Wiley Rein LLP on

The United States District Court for the Central District of California, applying California law, has held that an insurer could rescind liability insurance policies based on misrepresentations in the application, even though...more

Wiley Rein LLP

Coverage Barred by Prior Acts Exclusion Under First Policy; No Coverage Under Second Policy Because Defendant did not Qualify as...

Wiley Rein LLP on

The United States District Court for the District of New Mexico, applying New Mexico law, has held that a prior acts exclusion in a directors and officers policy barred coverage for an investor lawsuit alleging a scheme to...more

Goldberg Segalla

Fraud Doesn’t Pay in New York – May 2025 Update

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As a part of our quarterly practice group update, we are pleased to produce our latest installation with examples of our continued success in fraud litigation. This is our fourth year of this publication, and in February...more

Orrick, Herrington & Sutcliffe LLP

Pennsylvania governor launches new consumer protection tools

Recently, Pennsylvania Governor Josh Shapiro announced that he launched a new centralized consumer protection hotline, website and email address to assist Pennsylvanians in reporting scams and resolving financial and...more

Sheppard Mullin Richter & Hampton LLP

Umbrella Insurer’s “Business Decision” to Pick Up an Insured’s Defense Leads to a Multi-Million Dollar Fraudulent Concealment...

A primary insurer (Truck Insurance Exchange) and an umbrella insurer (Federal Insurance Company) have been involved in a series of lawsuits dating back to 2007. The California Court of Appeal recently ruled that their...more

Zelle  LLP

Further Clarity Regarding Coverage for Funds Transfer Fraud

Zelle LLP on

At this point, your IT department has almost certainly warned you to approach your e-mail inbox with skepticism--for good reason. Cybercriminals regularly and effectively impersonate our legitimate contacts for illegitimate...more

Goldberg Segalla

Fraud Doesn’t Pay in New York – February 2025 Update

Goldberg Segalla on

As a part of our Quarterly Practice Group Update, we are pleased to produce another installment with examples of our continued success in the area of fraud litigation. The New York State Workers’ Compensation Board has...more

Carlton Fields

A Bridge Too Far: Pennsylvania Federal Court Declines to Extend Coverage Beyond Policy’s Plain and Unambiguous Terms

Carlton Fields on

It’s apt to name a blog post after one of history’s great action movies when the case involves a “conceptual artillery duel” that “ends in a draw,” and that is exactly how U.S. District Judge Gerald Austin McHugh Jr. of the...more

Miller Nash LLP

The Northwest Policyholder | When the Application is the Risk: Application-Based Insurance Policy Rescission

Miller Nash LLP on

Surprised insurers are unhappy insurers. And unhappy insurers are more likely to resist paying claims. As are insurers who fail to heed their good faith and other obligations to their policyholders. So if you seek coverage...more

Wiley Rein LLP

New Jersey Appellate Court Affirms Rescission of Policies Based on Law Firm’s Misrepresentation in Applications

Wiley Rein LLP on

In a win for Wiley’s client, a New Jersey appellate court, applying New Jersey law, affirmed a trial court’s decision rescinding four lawyer’s professional liability policies because of material misrepresentations made in the...more

Wiley Rein LLP

Lending Exclusion in Bankers Professional Liability Policy Bars Coverage For Claim Alleging Financing a Ponzi Scheme

Wiley Rein LLP on

The United States District Court for the Central District of California, applying California law, has held that a lending exclusion in a bankers professional liability policy barred coverage for underlying lawsuits alleging...more

Marshall Dennehey

Appellate Court Affirms Ruling a Sworn Proof of Loss and Estimate Related to Later Claim Was Inadmissible as Hearsay and...

Marshall Dennehey on

Universal Property & Casualty Insurance Company v. Luis Nacimiento, Fla. 3rd DCA, 3D23-0301, Apr. 3, 2024 - The insured reported a claim to Universal Casualty & Property Insurance Company in February 2016 for water damage...more

Goldberg Segalla

Fraud Doesn't Pay in New York – August 2024 Update

Goldberg Segalla on

As a part of our Quarterly Practice Group Update, we are pleased to produce our latest installment of our continued success in fraud litigation. This report was originally conceptualized three years ago as a one-time...more

Robins Kaplan LLP

AI’s Impact on Property Insurance Coverage

Robins Kaplan LLP on

Artificial Intelligence (AI) is the simulation of human intelligence processes by machines, such as computer systems for assistance in quickly answering complicated questions, researching a specific topic, or creating an...more

Segal McCambridge

Michigan Supreme Court Cracks Down on Fraud in Claims filed with the MAIPF: Honesty Matters Throughout the Process

Segal McCambridge on

Car insurance plays a crucial role in protecting drivers and their finances after an accident. It provides financial support for medical bills, lost wages, and car repairs. However, a recent Michigan Supreme Court decision in...more

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