This document outlines an agenda for a conference session on proving insurance fraud. The agenda covers rescission checklists, claim strategies, litigation strategies, and trial strategies. It also provides details on several items to consider in a rescission checklist, including ensuring you have a complete file, understanding the governing law, identifying any misrepresentations or concealment by the applicant, and assessing delivery of the policy and use of conditional receipts. The goal is to eliminate liability for fraudulent claims while reducing legal fees and costs.
Normas Brasileiras de Contabilidade Aplicadas ao Setor Público - NBCASPJetro Missias
Este documento apresenta as Normas Brasileiras de Contabilidade Aplicadas ao Setor Público (NBCASP), definindo conceitos-chave como patrimônio público, sistema contábil e subsistemas de informações. É recomendada a leitura das normas para questões sobre Contabilidade Aplicada ao Setor Público.
This document summarizes the evolution of long-term care insurance policies from the 1970s to present. It discusses how early policies only covered nursing home care and had indemnity-based benefits. Over time, policies became more comprehensive to include home care and had expense reimbursement structures. The claims process also evolved from small paper-based operations to larger departments using electronic systems. The document outlines challenges in ensuring legal/regulatory compliance and effectively utilizing resources to adjudicate complex long-term care insurance claims.
The document discusses several key topics regarding ethics in nursing research:
1. Nursing research must conform to moral, ethical and legal standards to protect human welfare and subjects' rights.
2. Core principles of ethics like beneficence, justice and human dignity must be followed to ensure subjects' rights and welfare.
3. Guidelines like the Nuremberg Code and Declaration of Helsinki provide standards for informed consent, assessment of risks/benefits, and protection of vulnerable groups in research.
Cultural safety is an important concept in nursing practice that takes into account factors like culture, language, and spiritual beliefs. Unsafe cultural practices can negatively impact a person's health and cultural identity. The document discusses how nurses must consider various cultural influences to provide respectful and appropriate care to indigenous Australians.
This document discusses the use of neutrals in electronic discovery (ESI) mediation. It notes that ESI takes many forms and is a major part of discovery, resulting in increased disputes and costs. Engaging a neutral early can help parties develop an ESI discovery plan to address issues like preservation, search terms, and production formats. A neutral can facilitate cooperation and proportionality to control costs. Both state and federal rules have been amended to better address ESI discovery and sanctions. Mediation seeks to identify practical solutions, maintain self-determination, and avoid sanctions. Initial phone conferences can establish agendas to efficiently address technical ESI issues with experts. Hybrid mediation-arbitration processes like arb-med and
The document discusses developing a theory to prevent immigration marriage fraud for the United States Citizenship and Immigration Services. It aims to identify variables that relate to marriage fraud, such as policies and practices that allow fraud, enforcement of bad actors involved in fraud, and accurately defining marriage fraud and identifying instances of it. The theory would create a model of relationships between these variables, such as how full enforcement of immigration courts and actions against previous marriage fraud impact preventing current fraud.
Normas Brasileiras de Contabilidade Aplicadas ao Setor Público - NBCASPJetro Missias
Este documento apresenta as Normas Brasileiras de Contabilidade Aplicadas ao Setor Público (NBCASP), definindo conceitos-chave como patrimônio público, sistema contábil e subsistemas de informações. É recomendada a leitura das normas para questões sobre Contabilidade Aplicada ao Setor Público.
This document summarizes the evolution of long-term care insurance policies from the 1970s to present. It discusses how early policies only covered nursing home care and had indemnity-based benefits. Over time, policies became more comprehensive to include home care and had expense reimbursement structures. The claims process also evolved from small paper-based operations to larger departments using electronic systems. The document outlines challenges in ensuring legal/regulatory compliance and effectively utilizing resources to adjudicate complex long-term care insurance claims.
The document discusses several key topics regarding ethics in nursing research:
1. Nursing research must conform to moral, ethical and legal standards to protect human welfare and subjects' rights.
2. Core principles of ethics like beneficence, justice and human dignity must be followed to ensure subjects' rights and welfare.
3. Guidelines like the Nuremberg Code and Declaration of Helsinki provide standards for informed consent, assessment of risks/benefits, and protection of vulnerable groups in research.
Cultural safety is an important concept in nursing practice that takes into account factors like culture, language, and spiritual beliefs. Unsafe cultural practices can negatively impact a person's health and cultural identity. The document discusses how nurses must consider various cultural influences to provide respectful and appropriate care to indigenous Australians.
This document discusses the use of neutrals in electronic discovery (ESI) mediation. It notes that ESI takes many forms and is a major part of discovery, resulting in increased disputes and costs. Engaging a neutral early can help parties develop an ESI discovery plan to address issues like preservation, search terms, and production formats. A neutral can facilitate cooperation and proportionality to control costs. Both state and federal rules have been amended to better address ESI discovery and sanctions. Mediation seeks to identify practical solutions, maintain self-determination, and avoid sanctions. Initial phone conferences can establish agendas to efficiently address technical ESI issues with experts. Hybrid mediation-arbitration processes like arb-med and
The document discusses developing a theory to prevent immigration marriage fraud for the United States Citizenship and Immigration Services. It aims to identify variables that relate to marriage fraud, such as policies and practices that allow fraud, enforcement of bad actors involved in fraud, and accurately defining marriage fraud and identifying instances of it. The theory would create a model of relationships between these variables, such as how full enforcement of immigration courts and actions against previous marriage fraud impact preventing current fraud.
PROFESSIONAL EXCELLENCE TRAINING COURSE on APPEARANCE BEFORE NCLT AND QUASI JUDICIAL FORUMS.
Batch starting from Saturday, the 2nd July, 2016. Weekend Classes at Indian Law Institute, New Delhi.
Participation fee: INR 15,000/- per participant
The Key Takeaways for the course are:
• Course Material will be provided to the participants;
• Batch of 20 (maximum) participants for personalized training to develop and hone their negotiation, conciliation, drafting, presentation and arguments skills;
• Selected Video recordings relating to NCLT will be shared with participants;
• Certificate of Participation will be provided to the participants.
For registration or other clarifications, you may contact to:
Mr. Pawan Dubey: (+91) 9811516227 | pawan@lexbolster.com.
Detail of the course available at:
http://lexbolster.com/events_lexbolster.html
The document discusses several key concepts in public administration, including public policy, policy analysis, public choice theory, and administrative law. It describes public policy as actions taken by government to address perceived problems. Policy analysis aims to improve policymaking through rigorous analytical methodologies. Public choice theory examines individual behavior and decision-making within political systems. Administrative law governs rulemaking and adjudication by government agencies.
Current Issues in Securities RegulationNow Dentons
Mark Evans, a partner in the FMC Toronto office, was invited to speak at the Second Annual Securities Symposium this month about current issues in the area of Securities Regulation.
The passage discusses institutional racism in America and its effects. It notes that institutional racism exists in employment, education, medical services, and justice systems, negatively impacting people of color. While laws prohibit discrimination, institutional racism persists in subtle, systemic forms. The passage examines ongoing efforts to address disparate impact and fight all forms of institutional racism.
The document discusses different approaches to compliance and ethics programs. It argues that a dynamic approach using behavioral science, data, and positive language is more effective than a traditional prescriptive approach. A dynamic approach frames compliance in a rational, scientific context and emphasizes the benefits of compliance rather than penalties of non-compliance. It also tailors messaging to different levels in an organization by understanding their unique motivations and objectives. An effective program requires understanding an organization's business and adapting to motivate long-term, meaningful change.
The document discusses different approaches to compliance and ethics programs. It argues that a dynamic approach using behavioral science, data, and positive language is more effective than a traditional prescriptive approach. A dynamic approach frames compliance in a rational, scientific context and emphasizes the benefits of compliance rather than penalties of non-compliance. It also tailors messaging to different levels in an organization by understanding their unique motivations and objectives. An effective program requires understanding an organization's business and adapting to motivate long-term, meaningful change.
Running Head CRITICAL ANALYSIS OF THE WHISTLEBLOWER INCENTIVES .docxtodd271
Running Head: CRITICAL ANALYSIS OF THE WHISTLEBLOWER INCENTIVES 1
CRITICAL ANALYSIS OF THE WHISTLEBLOWER INCENTIVES AND PROTECTION 5
Doctor of Business Administration- Finance
Track- ADRP
Flexible Design Methods
Critical Analysis of the Whistleblower incentives and protection: Are a way of applying investment banking incentives to control management unethical and illegal practices
Introduction
Whistleblower incentives and protection refers to the monetary reward as well as protection which the United States Government offers to the individuals who exposes certain wrongdoings in the community more especially in government institutions. The Federal law requires the government to reward the whistleblowers a certain percentage of money that is recovered following their tips of exposing the wrongdoing acts. This percentage may go up to 30 percent of the total recovered money. In this paper, I will critically analyze whether Whistleblower Incentives and Protection are ways of applying investment banking incentives to control management unethical and illegal practices. And maybe are the whistleblowers rewarded accordingly in terms of security and money.
Problem Statement
What happened?? This is not anything like what was approved or what was in the white paper. Follow the instructions and make a paragraph out of the bullet outline problem
The Problem statement, which will be addressed in this paper, is that, whistle blowers are not given adequate incentives and protection resulting in the difficulty of reporting wrongdoing, misconduct and unethical behaviors. According to Andon, et al., (2018), Lack of whistle blower incentives and protection makes it difficult for whistle blowers to report wrongdoing, as they feel insecure. “The current whistle blowing system is not effective and therefore does not provide the basis for investigation of corruption cases and any misconduct within a company (Ballan, 2017). In support of Ballan’s views on the whistle blowing system, Keith, Todd & Oliver, (2016) indicated that the managers aren’t empowered to sanction employees involved in unethical behaviors because of lack of whistle blower incentives which are reinforced by the Federal laws.
Specifically, failure of finance department to offer adequate whistleblowers incentives as well as protection within the investment – banking sector in the United States. As per Keith, Todd & Oliver, (2016), in their recent research, they recommended that the finance department in any organization is a very critical area that can determine the overall performance of an organization. Failure to provide whistleblower incentives and protection to finance staff makes it difficult for them to report unethical behaviors.
Research Questions
What happened here? Where is the list of approved RQs Where are the numbers
It’s important to note that integrity and corruption free environment can be enhanced if specifically the involved organizations are audited or watch.
The Belmont Report (Three Benchmark Rules)ClinosolIndia
The Belmont Report, published in 1979, is a seminal document in the field of research ethics. It was developed by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in response to unethical research practices, particularly the infamous Tuskegee Syphilis Study. The report sets forth three fundamental ethical principles, often referred to as the "Three Benchmark Rules," that guide the ethical conduct of research involving human subjects. These principles are:
Respect for Persons:
The principle of respect for persons emphasizes the autonomy and dignity of individuals. It requires that individuals be treated as autonomous agents capable of making informed decisions about their participation in research. Researchers must obtain informed consent from potential subjects and provide them with all relevant information regarding the purpose, risks, benefits, and alternatives of the study. Special provisions must be made for individuals with diminished autonomy, such as children or those with cognitive impairments, to ensure their rights and welfare are protected.
Beneficence:
The principle of beneficence emphasizes the obligation to maximize benefits and minimize harm to research subjects. Researchers must ensure that the potential benefits of the study outweigh the potential risks. They should conduct a thorough risk-benefit analysis and design their studies to maximize potential benefits while minimizing any potential harm or discomfort to participants. Additionally, researchers must make ongoing assessments of the risks and benefits throughout the course of the study and take necessary steps to minimize harm and maximize benefits.
Justice:
The principle of justice requires the fair distribution of the burdens and benefits of research. It emphasizes the need for equal access to participation in research, regardless of factors such as race, gender, socioeconomic status, or other characteristics. Researchers must ensure that the selection of research subjects is fair and avoid exploiting vulnerable populations. Additionally, the benefits derived from research should be distributed equitably, ensuring that the burdens of research are not borne solely by disadvantaged groups while the benefits accrue to others.
These Three Benchmark Rules provided in the Belmont Report serve as the foundation for modern ethical guidelines and regulations governing research involving human subjects. They have significantly influenced the development of ethical review boards and informed consent processes, ensuring the protection of individuals' rights and well-being in research studies.
2016.05.17 Sifting_Through_Electronic_Trash_WayneTony Wayne
Tony Wayne is the president of IronHorse LLC, a business consulting firm specializing in valuation, forensic services, litigation support, and turnaround consulting. He has extensive experience investigating complex financial fraud cases involving stock scams, private placement fraud, and embezzlement. His work has contributed to both criminal convictions and civil litigation. The presentation provides an overview of techniques for effectively searching public records sites to compile background information and evidence for asset tracing, identifying relationships, and other forensic investigation activities. It also discusses using visualization tools like relationship maps and timelines to efficiently summarize complicated evidence in reports.
The document discusses the Restorative Engagement Program established by the Defence Abuse Response Taskforce in Australia. It was created as an alternative to traditional restorative justice programs, which were not practical given the context of abuse allegations against the Australian Defence Force. The Program allows victims to tell their stories of abuse to senior Defence representatives in a facilitated conference. Over 450 conferences have been held so far. The Program aims to acknowledge harm experienced by victims and drive cultural change within the Defence Force to prevent future abuse.
The document discusses the Restorative Engagement Program established by the Defence Abuse Response Taskforce in Australia. It was created as an alternative to traditional restorative justice programs, which were not practical given the context of abuse allegations against the Australian Defence Force. The Program allows victims to tell their stories of abuse to senior Defence representatives in a facilitated conference. Over 450 conferences have been held so far. The Program aims to acknowledge harm experienced by victims and drive cultural change within the Defence Force to prevent future abuse.
Freescale Semiconductors, Inc. Student name Course Date .docxhanneloremccaffery
Freescale Semiconductors, Inc.
Student name
Course
Date
Additional laws and harsher penalties
harsher penalties acts as a deterrent to crime
Additional laws to cover the loophole used to fraud
Hefty fines prohibits engagement in crime
Increases compliance with the laws
Human beings who have a tendency to break laws run Corporates. However having harsher penalties acts as a deterrent to committing a crime since they are afraid of penalties and severe fines to be paid. Having additional laws to cover the loophole used by the executives to commit unethical or fraudulent acts. Also having Hefty fines and increases, supervision prohibits engagement in crime as well as increases compliance with the laws
2
1. strategies to eliminate or mitigate insider trading
Preventing information that is non public from circulating
Such information denies perfect knowledge to investors
Increases the cost of stock through hoarding information
Only fully disclosed information should circulate
Insider trading happens when a few people, usually the executives, hold confidential information about the trading activities of the firm. One of the ways of preventing insider trading is by preventing information that is nonpublic from circulating within the market. This requires a full disclosure by the firms concerning the intended trading activities of the company. Having nonpublic information in circulation denies perfect knowledge to investors as well as increases the cost of stock through hoarding information for personal gains. However, when the information is public, the price will remain low and eliminate the privilege of knowing first (Legal Information Institute, 2013).
3
2. strategies to eliminate or mitigate insider trading
Restricting the time where the top executives of a firm can sell the shares awarded to them to an automatic pre arranged plan
The stock option awarded to top executives be sold at pre agreed time
Automatic time of selling stock eliminates making deals with investors
Makes the information publicly available
Most corporates reduce the cost of holding top-level executive through stock options. However to deter insider trading, restricting the time where the top executives of a firm can sell the shares awarded to them to an automatic pre-arranged plan should be followed. This restriction removes the hoarding of the investment information by the executives. There should be a clearly defined timeline when the executives sell their stock option, only after they have received their compensation and not before being compensated (Gandel, 2012).
4
3. strategies to eliminate or mitigate insider trading
Ban the payment of the executives using the stock options
Eliminates the unfair investment information holding by executives
Firms to seek other alternatives of paying executives
Continued of stock options makes executives hold information others don’t have
The most useful tool would be a total ban the paymen ...
Here are some effective ways to uncover hidden assets:
- Thoroughly review tax returns, bank statements, credit card statements, and other financial documents for inconsistencies
- Search public records like property records and lawsuits for unreported assets
- Hire a forensic accountant to thoroughly analyze financial records if inconsistencies are found
- Conduct surveillance or have a private investigator follow the spouse's activities and financial transactions
- Use online search tools to research the spouse's business dealings, property ownership, and other financial activities
This document outlines an agenda and case studies for a presentation on complex claims investigations. The presentation covers contestable investigations, suicide investigations, accidental death policies, and critical illness riders. Case studies are provided for each topic, describing fact scenarios and policy provisions. The purpose is to identify relevant questions to ask given the specific facts and contract language. The goal is to have a fair and consistent process for rendering reasonable claims decisions. Attendees are encouraged to ask questions.
This document summarizes a presentation on long term care given at an annual insurance conference. It discusses the history and evolution of long term care options and insurance from the 1970s to present. In the early years, nursing homes were the primary option and coverage was limited. Over the decades, more options like assisted living and home care emerged, as did more comprehensive insurance policies. The presentation concludes by asking questions about lessons learned, gaps that still need addressed, and the future of long term care delivery.
PROFESSIONAL EXCELLENCE TRAINING COURSE on APPEARANCE BEFORE NCLT AND QUASI JUDICIAL FORUMS.
Batch starting from Saturday, the 2nd July, 2016. Weekend Classes at Indian Law Institute, New Delhi.
Participation fee: INR 15,000/- per participant
The Key Takeaways for the course are:
• Course Material will be provided to the participants;
• Batch of 20 (maximum) participants for personalized training to develop and hone their negotiation, conciliation, drafting, presentation and arguments skills;
• Selected Video recordings relating to NCLT will be shared with participants;
• Certificate of Participation will be provided to the participants.
For registration or other clarifications, you may contact to:
Mr. Pawan Dubey: (+91) 9811516227 | pawan@lexbolster.com.
Detail of the course available at:
http://lexbolster.com/events_lexbolster.html
The document discusses several key concepts in public administration, including public policy, policy analysis, public choice theory, and administrative law. It describes public policy as actions taken by government to address perceived problems. Policy analysis aims to improve policymaking through rigorous analytical methodologies. Public choice theory examines individual behavior and decision-making within political systems. Administrative law governs rulemaking and adjudication by government agencies.
Current Issues in Securities RegulationNow Dentons
Mark Evans, a partner in the FMC Toronto office, was invited to speak at the Second Annual Securities Symposium this month about current issues in the area of Securities Regulation.
The passage discusses institutional racism in America and its effects. It notes that institutional racism exists in employment, education, medical services, and justice systems, negatively impacting people of color. While laws prohibit discrimination, institutional racism persists in subtle, systemic forms. The passage examines ongoing efforts to address disparate impact and fight all forms of institutional racism.
The document discusses different approaches to compliance and ethics programs. It argues that a dynamic approach using behavioral science, data, and positive language is more effective than a traditional prescriptive approach. A dynamic approach frames compliance in a rational, scientific context and emphasizes the benefits of compliance rather than penalties of non-compliance. It also tailors messaging to different levels in an organization by understanding their unique motivations and objectives. An effective program requires understanding an organization's business and adapting to motivate long-term, meaningful change.
The document discusses different approaches to compliance and ethics programs. It argues that a dynamic approach using behavioral science, data, and positive language is more effective than a traditional prescriptive approach. A dynamic approach frames compliance in a rational, scientific context and emphasizes the benefits of compliance rather than penalties of non-compliance. It also tailors messaging to different levels in an organization by understanding their unique motivations and objectives. An effective program requires understanding an organization's business and adapting to motivate long-term, meaningful change.
Running Head CRITICAL ANALYSIS OF THE WHISTLEBLOWER INCENTIVES .docxtodd271
Running Head: CRITICAL ANALYSIS OF THE WHISTLEBLOWER INCENTIVES 1
CRITICAL ANALYSIS OF THE WHISTLEBLOWER INCENTIVES AND PROTECTION 5
Doctor of Business Administration- Finance
Track- ADRP
Flexible Design Methods
Critical Analysis of the Whistleblower incentives and protection: Are a way of applying investment banking incentives to control management unethical and illegal practices
Introduction
Whistleblower incentives and protection refers to the monetary reward as well as protection which the United States Government offers to the individuals who exposes certain wrongdoings in the community more especially in government institutions. The Federal law requires the government to reward the whistleblowers a certain percentage of money that is recovered following their tips of exposing the wrongdoing acts. This percentage may go up to 30 percent of the total recovered money. In this paper, I will critically analyze whether Whistleblower Incentives and Protection are ways of applying investment banking incentives to control management unethical and illegal practices. And maybe are the whistleblowers rewarded accordingly in terms of security and money.
Problem Statement
What happened?? This is not anything like what was approved or what was in the white paper. Follow the instructions and make a paragraph out of the bullet outline problem
The Problem statement, which will be addressed in this paper, is that, whistle blowers are not given adequate incentives and protection resulting in the difficulty of reporting wrongdoing, misconduct and unethical behaviors. According to Andon, et al., (2018), Lack of whistle blower incentives and protection makes it difficult for whistle blowers to report wrongdoing, as they feel insecure. “The current whistle blowing system is not effective and therefore does not provide the basis for investigation of corruption cases and any misconduct within a company (Ballan, 2017). In support of Ballan’s views on the whistle blowing system, Keith, Todd & Oliver, (2016) indicated that the managers aren’t empowered to sanction employees involved in unethical behaviors because of lack of whistle blower incentives which are reinforced by the Federal laws.
Specifically, failure of finance department to offer adequate whistleblowers incentives as well as protection within the investment – banking sector in the United States. As per Keith, Todd & Oliver, (2016), in their recent research, they recommended that the finance department in any organization is a very critical area that can determine the overall performance of an organization. Failure to provide whistleblower incentives and protection to finance staff makes it difficult for them to report unethical behaviors.
Research Questions
What happened here? Where is the list of approved RQs Where are the numbers
It’s important to note that integrity and corruption free environment can be enhanced if specifically the involved organizations are audited or watch.
The Belmont Report (Three Benchmark Rules)ClinosolIndia
The Belmont Report, published in 1979, is a seminal document in the field of research ethics. It was developed by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in response to unethical research practices, particularly the infamous Tuskegee Syphilis Study. The report sets forth three fundamental ethical principles, often referred to as the "Three Benchmark Rules," that guide the ethical conduct of research involving human subjects. These principles are:
Respect for Persons:
The principle of respect for persons emphasizes the autonomy and dignity of individuals. It requires that individuals be treated as autonomous agents capable of making informed decisions about their participation in research. Researchers must obtain informed consent from potential subjects and provide them with all relevant information regarding the purpose, risks, benefits, and alternatives of the study. Special provisions must be made for individuals with diminished autonomy, such as children or those with cognitive impairments, to ensure their rights and welfare are protected.
Beneficence:
The principle of beneficence emphasizes the obligation to maximize benefits and minimize harm to research subjects. Researchers must ensure that the potential benefits of the study outweigh the potential risks. They should conduct a thorough risk-benefit analysis and design their studies to maximize potential benefits while minimizing any potential harm or discomfort to participants. Additionally, researchers must make ongoing assessments of the risks and benefits throughout the course of the study and take necessary steps to minimize harm and maximize benefits.
Justice:
The principle of justice requires the fair distribution of the burdens and benefits of research. It emphasizes the need for equal access to participation in research, regardless of factors such as race, gender, socioeconomic status, or other characteristics. Researchers must ensure that the selection of research subjects is fair and avoid exploiting vulnerable populations. Additionally, the benefits derived from research should be distributed equitably, ensuring that the burdens of research are not borne solely by disadvantaged groups while the benefits accrue to others.
These Three Benchmark Rules provided in the Belmont Report serve as the foundation for modern ethical guidelines and regulations governing research involving human subjects. They have significantly influenced the development of ethical review boards and informed consent processes, ensuring the protection of individuals' rights and well-being in research studies.
2016.05.17 Sifting_Through_Electronic_Trash_WayneTony Wayne
Tony Wayne is the president of IronHorse LLC, a business consulting firm specializing in valuation, forensic services, litigation support, and turnaround consulting. He has extensive experience investigating complex financial fraud cases involving stock scams, private placement fraud, and embezzlement. His work has contributed to both criminal convictions and civil litigation. The presentation provides an overview of techniques for effectively searching public records sites to compile background information and evidence for asset tracing, identifying relationships, and other forensic investigation activities. It also discusses using visualization tools like relationship maps and timelines to efficiently summarize complicated evidence in reports.
The document discusses the Restorative Engagement Program established by the Defence Abuse Response Taskforce in Australia. It was created as an alternative to traditional restorative justice programs, which were not practical given the context of abuse allegations against the Australian Defence Force. The Program allows victims to tell their stories of abuse to senior Defence representatives in a facilitated conference. Over 450 conferences have been held so far. The Program aims to acknowledge harm experienced by victims and drive cultural change within the Defence Force to prevent future abuse.
The document discusses the Restorative Engagement Program established by the Defence Abuse Response Taskforce in Australia. It was created as an alternative to traditional restorative justice programs, which were not practical given the context of abuse allegations against the Australian Defence Force. The Program allows victims to tell their stories of abuse to senior Defence representatives in a facilitated conference. Over 450 conferences have been held so far. The Program aims to acknowledge harm experienced by victims and drive cultural change within the Defence Force to prevent future abuse.
Freescale Semiconductors, Inc. Student name Course Date .docxhanneloremccaffery
Freescale Semiconductors, Inc.
Student name
Course
Date
Additional laws and harsher penalties
harsher penalties acts as a deterrent to crime
Additional laws to cover the loophole used to fraud
Hefty fines prohibits engagement in crime
Increases compliance with the laws
Human beings who have a tendency to break laws run Corporates. However having harsher penalties acts as a deterrent to committing a crime since they are afraid of penalties and severe fines to be paid. Having additional laws to cover the loophole used by the executives to commit unethical or fraudulent acts. Also having Hefty fines and increases, supervision prohibits engagement in crime as well as increases compliance with the laws
2
1. strategies to eliminate or mitigate insider trading
Preventing information that is non public from circulating
Such information denies perfect knowledge to investors
Increases the cost of stock through hoarding information
Only fully disclosed information should circulate
Insider trading happens when a few people, usually the executives, hold confidential information about the trading activities of the firm. One of the ways of preventing insider trading is by preventing information that is nonpublic from circulating within the market. This requires a full disclosure by the firms concerning the intended trading activities of the company. Having nonpublic information in circulation denies perfect knowledge to investors as well as increases the cost of stock through hoarding information for personal gains. However, when the information is public, the price will remain low and eliminate the privilege of knowing first (Legal Information Institute, 2013).
3
2. strategies to eliminate or mitigate insider trading
Restricting the time where the top executives of a firm can sell the shares awarded to them to an automatic pre arranged plan
The stock option awarded to top executives be sold at pre agreed time
Automatic time of selling stock eliminates making deals with investors
Makes the information publicly available
Most corporates reduce the cost of holding top-level executive through stock options. However to deter insider trading, restricting the time where the top executives of a firm can sell the shares awarded to them to an automatic pre-arranged plan should be followed. This restriction removes the hoarding of the investment information by the executives. There should be a clearly defined timeline when the executives sell their stock option, only after they have received their compensation and not before being compensated (Gandel, 2012).
4
3. strategies to eliminate or mitigate insider trading
Ban the payment of the executives using the stock options
Eliminates the unfair investment information holding by executives
Firms to seek other alternatives of paying executives
Continued of stock options makes executives hold information others don’t have
The most useful tool would be a total ban the paymen ...
Here are some effective ways to uncover hidden assets:
- Thoroughly review tax returns, bank statements, credit card statements, and other financial documents for inconsistencies
- Search public records like property records and lawsuits for unreported assets
- Hire a forensic accountant to thoroughly analyze financial records if inconsistencies are found
- Conduct surveillance or have a private investigator follow the spouse's activities and financial transactions
- Use online search tools to research the spouse's business dealings, property ownership, and other financial activities
This document outlines an agenda and case studies for a presentation on complex claims investigations. The presentation covers contestable investigations, suicide investigations, accidental death policies, and critical illness riders. Case studies are provided for each topic, describing fact scenarios and policy provisions. The purpose is to identify relevant questions to ask given the specific facts and contract language. The goal is to have a fair and consistent process for rendering reasonable claims decisions. Attendees are encouraged to ask questions.
This document summarizes a presentation on long term care given at an annual insurance conference. It discusses the history and evolution of long term care options and insurance from the 1970s to present. In the early years, nursing homes were the primary option and coverage was limited. Over the decades, more options like assisted living and home care emerged, as did more comprehensive insurance policies. The presentation concludes by asking questions about lessons learned, gaps that still need addressed, and the future of long term care delivery.
This document provides an overview and update on health insurance law and litigation related to the Patient Protection and Affordable Care Act (PPACA). It summarizes key provisions and goals of the PPACA related to increasing access and affordability of health insurance. It also reviews major litigation challenging various aspects of the PPACA, including the individual and employer mandates, Medicaid expansion, and preventive care coverage mandate. The document analyzes the Supreme Court's rulings upholding most provisions of the PPACA and discusses ongoing implementation and compliance issues.
The Affordable Care Act Upheld: Now What for Our Clients?Rob Pohls
On June 28, 2012, the Supreme Court issued its decision in a trio of cases which challenged the constitutionality of certain provisions in the Affordable Care Act. Ultimately, a majority of the justices concluded that the Act’s “individual mandate” was not authorized by the Commerce Clause. U.S. Const. Art. I, §8, cl. 3. At the same time, though, a different majority of the justices concluded that the provision was within Congress’ power to “lay and collect taxes.” U.S. Const. Art. I, §8, cl. 1. The Affordable Care Act therefore has survived its primary constitutional challenges to date. To be sure, the public remains divided in its support for the legislation, and the national election in November 2012 is likely to spark further debate about whether to expand, contract or otherwise substantively change the Affordable Care Act. In the meantime, the Affordable Care Act still promises to have a profound impact on health insurers, employers and virtually every American citizen. An understanding of the Affordable Care Act’s main provisions and the key changes for which they call therefore is essential to the advice we can provide to our clients.
Making Sense of the Interplay Between Securities Law/Broker-Dealer Rules and ...Rob Pohls
The presentation discussed the complex interplay between insurance law, securities law, and trust law as they relate to the sale and ownership of variable insurance products, highlighting issues around standing, damages, duties of agents and brokers, and performance of insurance contracts and investment choices. Key topics included determining who has standing to bring claims or lawsuits and understanding the duties insurance agents and brokers owe to policyowners.
What Do Health Insurance Litigators Face in 2012 and Beyond?Rob Pohls
This document provides an overview of the key legal challenges that health insurance litigators may face in 2012 and beyond related to the Affordable Care Act. It summarizes the pending Supreme Court case challenging the constitutionality of the individual mandate provision. The document outlines the four questions that will be addressed by the Supreme Court related to whether the individual mandate is a tax, if it exceeds Congress' powers under the Commerce Clause, and whether it is severable from the rest of the Act if found unconstitutional. It provides background on the Commerce Clause and relevant case law informing each question.
This document discusses post-claim underwriting and how to avoid it. It defines post-claim underwriting as when an insurer chooses not to pursue or complete its underwriting of a risk until after a claim is made. This can expose insurers to claims that they improperly delayed investigating important information about an applicant's eligibility until a claim occurred. The document examines the legal elements required to form a valid contract, as well as defenses that allow for contract rescission due to issues affecting consent like mistakes, misrepresentations, fraud and more. It provides examples of state insurance laws regarding the right to rescind a policy.
The document discusses key provisions of the 2010 Patient Protection and Affordable Care Act (ACA) regarding health care reform. It outlines requirements for health plans to cover adult children until age 26, not impose lifetime or annual limits on coverage, cover preventive services with no cost sharing, and prohibit pre-existing condition exclusions. It also describes the establishment of state-based health insurance exchanges and qualifications for plans to be offered through the exchanges. Minimum coverage levels for plans ranging from bronze to platinum are defined. The implementation timeline for various ACA provisions from 2010 to 2018 is provided.
National Health Care Reform: What is it and What Does it Mean to You?Rob Pohls
The document outlines an agenda for a panel discussion on national health care reform. It will feature presentations from Karen Davenport of the Center for American Progress, Robert Moffit of the Heritage Foundation, and Robert Smoldt of Mayo Clinic. The panel will discuss key questions around the goals and implementation of the Affordable Care Act, including how it will impact costs, coverage, and the health care system. The event will take place on October 21, 2010 at the San Diego Marriott Hotel & Marina.
The document provides an overview of key provisions and implementation timeline of the Patient Protection and Affordable Care Act (ACA). It establishes health insurance exchanges by 2014 to facilitate the purchase of qualified health plans. The ACA also defines essential health benefits that must be covered and establishes different coverage levels (bronze, silver, gold, platinum). Health insurers must offer at least one silver and one gold plan on the exchanges.
The document discusses scenarios that long term care claim handlers may encounter and how to best handle them. It explores what makes a good long term care claim handler and how to avoid errors. The scenarios involve situations like an insured seeking advice, a claim where care needs changed over time, dealing with conflicting family information, coverage questions for assistance with transportation and household tasks, and determining coverage for a couple moving into an assisted living facility. The presentation aims to identify best practices for long term care claims handling.
This document summarizes strategies for preparing for mediation of disputed health insurance claims. It provides tips for mediators, in-house counsel, and outside counsel. Key steps include understanding expectations, identifying non-monetary barriers, and allowing plaintiffs to tell their story. The background section describes a hypothetical disputed claim involving denial of coverage for a deceased spouse's medical bills and the surviving spouse's subsequent hospitalization.
Proving Insurance Fraud: Real Case StudiesRob Pohls
This case involves a $50,000 life insurance policy where the proposed insured, Stacey, died one day after the policy was approved. The insurer investigated and found inconsistencies in the application and interviews. Medical records showed Stacey had significant health issues contradicting the application. The insurer denied the claim, suspecting insurance fraud by the applicant and beneficiary, Cynthia and her children.
Legal Considerations In Life Insurance (2010 09 23)Rob Pohls
The document outlines various legal considerations related to life insurance contracts. It discusses requirements for forming valid contracts such as having consent between capable parties, lawful objectives, and consideration. Specific issues covered include insurable interest requirements, stranger-owned life insurance restrictions, consent and how it can be impacted by factors like duress or mistake. Grounds for rescinding contracts such as fraud, misrepresentation and materiality are also summarized. The document appears to be presentation materials for a seminar on life insurance legal issues.
This document provides an overview of a presentation on life insurance cases involving disputed benefit claims related to sex, drugs, violence and other factors. The presentation addresses topics such as contract formation, contestability and rescissions, changes in an applicant's health status, and misrepresentations in insurance applications. Case studies are presented on issues such as when an insurance contract is formed, temporary insurance coverage, what information must be disclosed in an application, and standards for rescinding a policy due to misrepresentation or nondisclosure.
This document provides an agenda and overview for a presentation on long term care insurance, including the role and state of the industry, product details, challenging policy provisions, and a litigation report. It discusses the growing need for long term care as the population ages but low preparation among Americans, and challenges facing the industry including underpricing of policies and difficulty accessing benefits.
1. Proving
INSURANCE FRAUD
Steven P. Del Mauro
McElroy, Deutsch, Mulvaney & Carpenter, LLP
Newark, New Jersey
Robert R. Pohls
Pohls & Associates
Los Angeles, California
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
2. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
1. Rescission Checklist
2. Real Case Study
a. Claim Strategies
b. Litigation Strategies
c. Trial Strategies
3. Questions
2
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
3. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Purpose Developed to train young associate lawyers as a guide
and to assist in issue spotting.
Goals - To provide a thorough, complete and fair review of
each claim.
- To eliminate or greatly reduce the company’s liability
and exposure to extra-contractual liability/bad-faith.
- “Tee-up” the case – achieve rescission while
substantially reducing attorney fees and costs.
NO SURPRISES!
3
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
4. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
5. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
1. Do I have the complete file?
- All coverage(s) with the company.
- Correct policy forms with all riders.
- All signed application forms, especially the delivery
requirements.
- Conditional receipt form.
- Applicable underwriting guidelines.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
6. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
1. Do I have the complete file?
- Recording of inspection report/telephone verification.
- Premium/Billing information.
- Outstanding or incomplete investigation.
- Medical record requests (time period).
- Inspect original application documents to assess the
appearance of alteration – different handwriting or color ink.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
7. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
2. Governing Law – contractual rights
- New Jersey vs. Arizona.
- ERISA – DOL claim guidelines?
- Within 2 years of issuance or beyond.
- Review the language of the incontestable clause.
- except for fraudulent misstatements.
- tolling/accordion.
- strict two years.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
8. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
2. Governing Law – contractual rights
- Legal Fraud.
- Equitable Fraud.
- Does jurisdiction require proof that misrepresented or
concealed medical condition is cause of loss?
- If policy is not contestable, are you in a jurisdiction where
you still have recourse?
- ex., New Jersey Insurance Fraud Prevention Act.
- ex., Waiver of premium rider/life insurance
- Alternate basis to adjudicate claim?
- ex., Pre-existing condition limitation provision.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
9. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
3. Misrepresentation/Concealment
- Misrepresentation/concealment on the application(s).
- Misrepresentation and concealment of a material change
in health during underwriting.
- Or both.
- Any medical information we developed during the claim
which reflects medical consultation, diagnosis and/or
treatment during underwriting of the policy.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
10. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
3. Misrepresentation/Concealment
- Conditional Receipt
- When did we get the money?
- Generally two types providing different contractual rights:
1) Simply provides coverage if conditions are met,
with a beginning and end date.
2) Fixes a date for determining insurability, if
conditions are met. Changes in health occurring
thereafter are ignored in determining insurability.
- Negligent delay in underwriting the policy.
- Length of time to underwrite in comparison to
company standards.
- Cause of delay 10
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
11. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
3. Misrepresentation/Concealment
- How was the policy delivered?
- Mail
- In person
- No conditional receipt coupled with change in health
– why?
- Was conditional receipt offered and refused?
- Negligence per se rules; Brill v. Guardian Life Insurance
Company of America.
- Underwriting Opinion.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
12. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
3. Misrepresentation/Concealment
- Misrepresentation/Concealment on Application
- All questions answered on application, including
related questions.
- Objective vs. subjective questions.
- ex.: “Have you ever received treatment for or been
diagnosed as having or had any of the following?”
- ex.: “Within the past 5 years have you had a
physical examination, medical consultation, X-ray or
laboratory study, or been a patient in a hospital or
other medical facility?”
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
13. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
3. Misrepresentation/Concealment
- Misrepresentation/Concealment on Application
- Medical, financial, over-insurance, avocations.
- Incomplete answers – details.
- Half truths.
- Misrepresentation to broker, paramedical, or both? Was
it affirmed during inspection report?
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
14. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
4. Underwriting
- Company’s requirements for age and amount of
insurance applied for.
- Complied with or waived
- ex.: APS requirement; tax returns; financial statements.
- Sources of information available to underwriter.
- ex.: MIB
- Any information developed during underwriting which is
inconsistent with the representations made on the
application which may give rise to the duty to inquire.
- ex.: APS
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
15. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
5. Underwriting Post-Loss
- Confirm the files reviewed by the underwriter.
- Were all grounds for rescission identified?
- Obtain and review underwriting guidelines that support
underwriters conclusion.
- Misrepresented fact must be “material.”
- black/white vs. exercise of discretion
- Conference with underwriter.
- Referral to medical director where applicable.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
16. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
6. Agent Misconduct
- Ascertain the producer’s relationship with the company
and with insured.
- Obtain agent statement.
- Obtain agent’s files.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
17. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
7. Confront Insured
Did we provide the insured with an opportunity to explain the
apparent inconsistency between the information represented
on the insurance applications and that developed during the
investigation of the claim?
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
18. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
8. Rescission of a Reinstated Policy
- Was there a valid lapse of the policy without value?
- Alternate basis for claim adjudication.
- ex.: The reinstated policy will only cover disabilities
due to injury occurring after the date of reinstatement,
and due to sickness beginning more than 10 days after
that date.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
19. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
9. Estoppel/Waiver During Claim Handling
Inconsistent positions are to be avoided like the plague.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
20. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
10. Claim Determination
- Appropriate tone.
- Correctly cites all applicable policy provisions.
- Factually accurate.
- All basis for decision, including alternate grounds.
- Tender premium refund.
- Reserves all rights.
- Supervisor approval.
- Compliance with internal company procedures
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
21. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Proposed Insured: Stacey
Applicant/Owner: Cynthia
Proposed Beneficiaries: Cynthia’s 3 children (all minors)
Application:
· Completed in agent’s office (Los Angeles)
· Dated: March 17, 2004
· Physical Description: 32 years old
5’1” and 120 lbs.
· No Adverse Medical History
· No History of Tobacco Use
· Occupation: Unemployed
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
22. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Face Amount Applied For: $50,000
Monthly Premium: Less than $20/month
Cash With Application: First month’s premium
Signatures:
Cynthia (Applicant/Owner) Stacey
(Proposed Insured)
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
23. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
· No paramedical examination
· Oral specimen
· Collected at time of application
· Processed on March 24, 2004
· Negative results
· reported to insurer on March 26, 2004
· received by underwriter on April 27, 2004
· Paper application received April 27, 2004
· Additional underwriting requirements satisfied on May 3, 2004
· Underwriter approved application: 4:48 p.m. on May 5, 2004
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
24. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
· Pronounced dead at 6:20 a.m. on May 6, 2004
· Reported to agent (and insurer) on May 8, 2004
· Agent indicated he was told Stacey died of a heart attack.
· Agent informed Cynthia that insurer will conduct an
investigation because Stacey’s death occurred in the
contestable period.
· Claim kit sent on May 10, 2004
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
25. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Interview of Cynthia -- June 3, 2004
· Stacey had “never been ill and didn’t have a family
physician.”
· Stacey had gone to Houston to visit their mom and
became ill.
· Stacey was taken to “the largest trauma center in
Houston,” which is where she died.
· Cause of death is not yet known.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
26. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Interview of Stacey’s Mom -- June 9, 2004
· Stacey died of a “massive heart attack.”
· Stacey had been “physically healthy.”
· Stacey was mentally ill.
· Diagnosed with schizophrenia 10 years earlier
· Many “mental doctors” and medications.
· Stacey had been living in a nursing home in Southern CA.
· Had “breathing problems” in March 2004.
· Was moved to a Southern CA hospital for 4-5 days,
then transferred to hospital in Houston “to be
closer.”
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
27. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
My mama always said:
“IF YOU TELL ONE LIE, YOU’LL
HAVE TO TELL ANOTHER.”
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
28. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Claim Strategy Number 1:
Give ’em some rope.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
29. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Interview of Cynthia -- June 3, 2004
· Stacey had been “in and out of mental type institutes.”
· Someone asked her if she had insurance “in case
something happened to” Stacey.
· Picked Stacey up from a nursing home one day to go
shopping with two friends, then to agent’s office to sign the
application.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
30. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Interview of Cynthia -- June 3, 2004
· Did not remember any application questions being read
to her.
· Just “signed the application” where “she was told to.”
· Told the agent that “if something happened to her and her
sister, she wanted her [Cynthia’s] kids to be the
beneficiaries.”
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
31. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call from Cynthia -- June 9, 2004
· Reported that she has “only a 5th grade reading/writing
level.”
· Claimed she went to the agent because the insurer
indicated its agents would “do everything” for her.
· Trusted the agent “with everything.”
· Told the agent that:
· Stacey “was in a nursing home for mental
problems.”
· Cynthia was supposed to be the beneficiary, not
her kids.
· Friends and family told her to “get a lawyer.”
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
32. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Cynthia -- June 23, 2004
· No one asked any questions at the time of application.
· Claimed she called the agent’s office in January 2004 and
left a message:
· Stacey is mentally ill with schizophrenia.
· Could she take out a policy on Stacey?
· Claimed she called again in February 2004 and was told to
come to the office to get a policy on Stacey.
· Only one friend – Michele – went shopping with Cynthia
and Stacey and was present at the time of the application.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
33. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call from Cynthia -- July 22, 2004
· Claims agent came to her house 4 hours after learning of
Stacey’s death and told her to not file a claim:
· filled out some underwriting papers on his own.
· was afraid to lose his job.
· willing to pay money from own account if Cynthia
would not file a claim
· Claims agent made similar offer to Cynthia’s mother; agent
also called on Cynthia’s cell phone during Stacey’s funeral.
· Is “sure the agent is trying to trick her as she is sure the
agent forged her signature on the policy.”
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
34. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Cynthia – August 22, 2004
· Told the agent in January 2004 that Stacey was mentally ill
and living in a nursing home.
· One friend went with her and Stacey to the agent’s office to
sign the application on March 17, 2004 .
· “no questions were asked.”
· she and Stacey “both signed paperwork” where told.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
35. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Cynthia – August 22, 2004
· Stacey left Los Angeles for Houston on April 22, 2004.
· Stacey “got away from” her mother, became delusional, and
was admitted to hospital involuntarily.
· Stacey was discharged, then re-admitted after a week or
two, just before she died.
· Stacey was 5’1” or 5’2” and weighed about 260 lbs.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
36. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Claim Strategy Number 2:
Dig deep . . .
really deep.
36
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
37. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Agent -- June 9, 2004
· Only two people came to the office on the application date:
Cynthia and Stacey.
· All application questions were read aloud while displayed
on two computer monitors.
· Cynthia had no problem reading the questions.
· Cynthia had filled out forms for agent’s office
before and reportedly “prepared income taxes
for other people.”
· Stacey answered all the questions “No.”
37
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
38. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Agent -- June 9, 2004
· Cynthia specifically asked for her kids to be named as
primary beneficiaries.
· Cynthia and Stacey signed the application.
· Agent would not have taken the application if knew
Stacey was in a nursing home for mental problems.
38
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
39. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Agent – August 25, 2004
· Went to Cynthia’s house after learning of Stacey’s death
· Expressed condolences
· Explained claim process (contestable investigation)
· Denied offering any money to not make a claim
39
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
40. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Cynthia’s Mom – December 28, 2004
· Agent did call her after Stacey’s death
· Said did not think Cynthia could make a claim
· Offered money toward funeral expenses
· Agent also called Cynthia’s brother (Ernest)
· Said did not think Cynthia could make a claim
· Offered money toward funeral expenses
40
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
41. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Ernest – December 30, 2004
· Remembers agent calling after Stacey’s death
· Spoke only with Cynthia and Cynthia’s Mom
· Understood there might be a problem with policy
· Believes agent offered money toward funeral
expenses
41
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
42. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Medical Records
(California) Medical Center 6/17/2003 - 10/31/2003
(California) Care Center 10/31/2003 - 1/23/2004
(California) Hospital 1/23/2004 - 1/27/2004
(California) Nursing Home 1/27/2004 - 3/5/2004
(California) Hospital 3/5/2004 - 3/11/2004
(Texas) Hospital 3/14/2004 - 4/8/2004*
(Texas) Hospital E.R. 4/11/2004 - 4/12/2004
(Texas) Psych Ward 4/12/2004 - 5/6/2004
42
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
43. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Autopsy Report
Death was the result of “[c]ardiomegaly associated with
hypertensive cardiovascular disease,” secondary to obesity.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
44. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Medical Records
· hypertension, with non-compliance regarding
treatment and abnormal EKG’s associated with the
hypertension;
· asthma, COPD and pulmonary hypertension;
· obesity;
· congestive heart failure and cardiomegaly; and
· ten year history of mental/nervous disorders, including
numerous medications and institutional stays.
44
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
45. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Medical Records – (California) Hospital
3/5/2004 Admitted (SOB/aggressive behavior)
3/9/2004 “Cardiology assessment with COPD confirmed. . .
Discussed patient’s predicament last night by
phone with patient’s sister, Cynthia, and mother.
On learning of CHF, they agreed to permit . . .
development of appropriate Tx.”
3/11/2004 Discharged (to fly with Cynthia’s Mom to Texas)
45
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
46. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Claim Strategy Number 3:
Get them to
commit.
46
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
47. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Agent – August 25, 2004
· Came to office on date application was completed
· Called just before coming
· No prior calls, messages or discussions about Stacey
Letters from Agent and Agent’s Assistant
· Application completed on March 17, 2004
Telephone Call to Cynthia – December 20, 2004
· One friend – Michele – was with Cynthia and Stacey when
the application was signed in the agent’s office.
· Michele “moves around a lot” and cannot be contacted.
47
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
48. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Agent – August 25, 2004
· Cynthia specifically said she did not want to be named the
beneficiary.
· Cynthia gave no reason for not naming herself
Letters from Agent and Agent’s Assistant
· Cynthia asked that her three kids be named beneficiaries
48
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
49. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Agent – August 25, 2004
· Cynthia signed the application when it was filled out
Claim Form – January 18, 2005
· Addendum:
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
50. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Telephone Call to Agent – August 25, 2004
· Stacey signed the HIV consent form on the date the
application was completed
· Application was mailed to Cynthia’s home for Stacey to sign
HIV Consent Form Application
50
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
51. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Comparison of Signatures
HIV Consent Form Application
51
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
52. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Comparison of Signatures
HIV Consent Form Application
52
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
53. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Denial Letter – January 10, 2005
Our investigation indicates Stacey was confined in (Texas)
Hospital “in Houston, Texas from March 14, 2004 to April 8,
2004; therefore she could not have appeared in the agent’s
office in California to complete this application, as confirmed
by Cynthia in previous statements.”
In addition, “the application did not include information about the
insured’s history of schizophrenia, hypertension with non-
compliance regarding treatment, abnormal EKGs associated with
the hypertension, congestive heart failure, cardiomegaly, and
pulmonary hypertension during her confinement.”
53
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
54. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Real Case Study: Cynthia’s Kids v. Insurer and Agent
Attorney’s Response – February 27, 2005
· “On March 17, 2004, Stacey, Cynthia and a friend”
(Michele) went to the agent’s office.
· No one asked them questions.
· Neither of them signed a document with medical
questions.
· Cynthia left the office with a Binding Receipt.
· As of March 17, 2004, Stacey “was residing in a nursing
home in Pasadena California. To the extent any medical
records show Stacey residing in Texas as of that date, they
are in error.”
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
55. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Litigation Strategy Number 1:
Don’t bite off more than you can chew!
Proving fraud requires evidence of:
• Representation of fact
• Falsity
• Knowledge of falsity
• Intent to deceive
• Actual reliance
• Reasonable reliance
• Damage
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
56. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Basic Contract Principles
Every contract requires consenting parties. If there is mutual
assent to the subject matter of the agreement, a contract results.
However, it may be voidable when there is a harmful mistake as to
some basic or material fact that induced the aggrieved party to
enter it.
· If both parties are mistaken and neither is at fault (or both are
equally to blame), the mistake may prevent formation of a
contract.
· A contract formed when one party has made a unilateral
mistake is not voidable unless the other party had reason to
know of the mistake or his or her fault caused the mistake.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
57. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Insurance Laws
Ohio No answer to any interrogatory made by an applicant in his
application for a policy shall bar the right to recover upon
any policy issued thereon, or be used in evidence at any
trial to recover upon such policy, unless it is clearly proved
that such answer is willfully false, that it was fraudulently
made, that it is material, and that it induced the company to
issue the policy, that but for such answer the policy would
not have been issued, and that the agent or company had
no knowledge of the falsity or fraud of such answer.
Ohio Rev. Code §3911.06
See also, Ohio Rev. Code §3923.14
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
58. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Insurance Laws
No. Carolina “All statements or descriptions in any application for a
policy of insurance, or in the policy itself, shall be
deemed representations and not warranties, and a
representation, unless material or fraudulent, will not
prevent a recovery on the policy.”
N.C. Gen. Stat. §58-3-10
Illinois “No such misrepresentation or false warranty shall
defeat or avoid the policy unless it shall have been
made with actual intent to deceive or materially affects
either the acceptance of the risk or the hazard
assumed by the company.” 215 ILCS 5/154
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
59. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Insurance Laws
California “If a representation is false in a material point,
whether affirmative or promissory, the injured party
is entitled to rescind the contract from the time the
representation becomes false.”
Cal. Ins. Code §359
Whether the representation was intentionally or
unintentionally false does not alter the injured party's
right to rescind the policy.
. Telford v. New York Life Ins. Co., 9 Cal.2d 103, 105 (1937)
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
60. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Contract Language
Application Agreement:
“Coverage will be effective as of the policy date if the
following conditions are met:
· the first premium is paid when the policy is
delivered;
· the Proposed Insureds are living on the delivery
date; and
· on the delivery date, the information given to the
Company is true and complete without material
changes.
60
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
61. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Contract Language
Binding Receipt:
· “There is no coverage under this Receipt if the application
contains any material misrepresentation.”
· “No death benefit is provided by this Receipt unless death
results from an accident that occurs or an illness that first
manifests itself after the Application Date.”
· “Coverage under this Receipt will end when the first of the
following occurs: (a) The application is approved; (b)
Notice of disapproval of the application is given; (c) 60 days
have expired starting with the Application Date.”
61
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
62. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Litigation Strategy Number 2:
Be ready to herd some cats.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
63. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Letter from Attorney
“I have reviewed the underwriting and claim files. . . It
appears the initial meeting with the agent was probably in February
2004, at which time Cynthia was given a binding receipt post-dated
to March 17, 2004 (the date Cynthia would have premium funds
available).”
Cynthia: Went shopping before going to agent’s office
because had just received a tax refund.
Agent: No way to post-date binding receipt, and no
reason to do so.
Binding
Receipt: No coverage if application date is more than
60 days before death.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
64. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Cynthia’s Testimony
“I applied for the policy because the nursing home told us
that all patients have to have life insurance to be admitted. I
needed it so Stacey could get the care she needed.”
· Nursing home has no such policy and denies any such
discussion.
· Stacey was in a locked facility between January 27, 2004
and March 5, 2004 and only left on one date: a Saturday in
February.
· Agent’s office is closed on Saturdays.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
65. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Cynthia’s Testimony
“I told the agent that Stacey was in a nursing home, had
schizophrenia, was depressed and had hallucinations.”
· Agent would not have taken application if knew any of
those facts.
· If the underwriter had known of those facts, no further
inquiries would have been made: the application would
have been denied.
· An applicant who communicates some (but not all) facts
which are material to the risk he or she is trying to insure is
not excused from his or her failure to communicate other
facts which are material to that risk. Cal. Ins. Code §332.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
66. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Cynthia’s Testimony
“No one asked us any medical questions. The agent must
have filled out the application.”
· Agent had never met, talked to, or talked with anyone
about Stacey
· Address
· Date of Birth
· Social Security Number
· Agent had never met, talked to, or talked with anyone
about Cynthia’s kids
· all 3 are named in application
· all 3 have a different last name than Cynthia
66
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
67. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Cynthia’s Testimony
“Stacey never signed anything. The agent told me he signed
Stacey’s name to the application.”
· Cynthia previously admitted she and Stacey “signed where
told.”
· Agent clarified that application was mailed to Cynthia for
Stacey to sign.
· No dispute that signature on application was not genuine.
· Cynthia claims agent forged it.
· Agent though was genuine.
· Insurer contends it was signed by an imposter.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
68. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Cynthia’s Testimony
“I never signed the application.”
· Cynthia previously admitted she and Stacey “signed where
told.”
· Both handwriting experts agree that signature is genuine.
· Without a signature on the application, there is no
application and neither a binding receipt nor a policy.
68
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
69. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Trial Strategy Number 1:
Keep the
stories
straight.
69
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
70. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Underwriter’s Perspective
· 32 year old non-smoker
· 5’1” and 120 lbs.
· No adverse medical/psychiatric history
Claim Handlers’ Perspective
· 32 year old smoker
· “about” 260 lbs.
· Significant undisclosed medical/psychiatric history
· Imposter at point of sale
Jury’s Perspective
· 309 lbs.
· Cynthia and her mother were told she was dying
· Could not have been in agent’s office on either date
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
71. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Trial Strategy Number 2:
Let the facts speak for
themselves.
If they are enough
to prove fraud,
jurors will
see it.
71
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
72. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
Trial Strategy Number 3:
Remember the
“simple” truth.
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International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
73. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
73
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010
74. Proving RESCISSION CLAIM LITIGATION TRIAL
INSURANCE FRAUD AGENDA QUESTIONS
CHECKLIST STRATEGIES STRATEGIES STRATEGIES
QUESTIONS?
Steven P. Del Mauro Robert R. Pohls
McElroy, Deutsch, Mulvaney Pohls & Associates
& Carpenter, LLP Los Angeles, California
Newark, New Jersey Phone: 310.694.3092
Phone: 973.622.7711 Email: rpohls@califehealth.com
Email: sdelmauro@mdmc-law.com
74
International Claim Association – 2010 Annual Education Conference – Austin, Texas – October 4, 2010