Practice Areas & Industries: Goldberg Segalla LLP

 





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Practice/Industry Group Overview

Our insurance fraud attorneys regularly team with Special Investigation Units (SIU), as well as Claims and Auditing departments, to investigate and litigate claims involving suspected insurance fraud. We partner with our clients to develop solutions to insurance fraud, working in a manner that allows clients to quantify the impact and results of their anti-fraud activities.

Our group is typically involved in all aspects of the claim process, including:

  • Investigating the claim, taking examinations under oath and providing coverage opinions
     
  • Defending the denial of fraudulent claims and any related bad faith actions
     
  • Initiating litigation to recover amounts paid out on fraudulent claims
     
  • Filing declaratory judgment actions to prevent payment on claims
     
  • Developing and implementing insurance fraud initiatives to deter the filing of additional fraudulent claims

Insurance fraud may occur across various lines of coverage and at different stages of the process. For example, there may be underwriting/rate evasion fraud at policy inception, fabricated losses and post-loss claim enhancement. Our attorneys have a wealth of experience investigating and litigating claims, including handling litigation in state and federal courts. Some of the key issues our attorneys have addressed include:

  • Application and premium fraud
     
  • Discovery of hidden payroll in computer business records
     
  • Recovery of unpaid insurance premiums
     
  • Policy cancellation
     
  • Staged motor vehicle accident rings and thefts
     
  • Unlicensed medical providers
     
  • Medical provider billing eligibility and fraud
     
  • Business interruption losses
     
  • Identity fraud
     
  • Fraudulent employment discrimination claims
     
  • Property damage
     
  • Surety/fidelity bonds

Our attorneys have handled commercial lines premiums (premium recovery) for nursing homes, professional employer organizations (PEOs), security companies, and the construction and trucking industries. Our experience with personal line premiums include initiatives against medical providers, staged motor-vehicle accident rings, vehicle theft rings, property and auto claims, fraudulent claims for homeowner’s insurance benefits, personal automobile insurance application/premium fraud, and personal automobile staged theft claims.

We have a wide range of experience in civil, criminal and administrative litigation and are able to analyze a variety of claims and issues. We have experience in insurance coverage and defense as well as corporate, tax and commercial issues. Our attorneys publish articles and lecture regularly, in addition to frequent training programs involving both the insurance industry and law enforcement.

We provide full case analysis, including underwriting, audits, claims, coverage, fraud and defenses and take a proactive approach for the carrier. We are bottom-line driven and create integrated, result-based action plans in order to recover lost premiums and benefits wrongfully obtained by insured/claimants. We affirmatively challenge suspicious claims (declaratory judgment actions) and counterclaims when appropriate. When necessary, we target medical providers and other licensed professionals.

Our attorneys provide customized, in-house training programs on a variety of topics, including:

  • Red flags of premium fraud for auditors
     
  • Auditing of suspicious employers – what to review and prepare
     
  • How auditor’s familiarity with insured’s loss experience can facilitate discovery of fraud
     
  • The claims department’s role in facilitating discovery of fraud
     
  • Independent contractors – what to look for in an audit
     
  • Auditing problematic industries – construction, trucking and PEOs
     
  • The role of Underwriting in detecting potential fraud
     
  • The role of Loss Prevention in identifying potential fraud
     
  • Role playing for deposition and trial
     
  • Focus on identity and loss history as claim defenses
     
  • Strategic use of recorded interview and EUOs
     
  • Coordination with Audit, Claims and Underwriting to present a total analysis and defense
     
  • Licensure and eligibility concerns for analysis and coverage defenses
     
  • Insurance fraud initiatives – identifying problematic industries/claims/claimants/medical providers/carriers' goals and how to measure success