Staged-accident organizers send to prison for PIP fraud

August 18th, 2014


The gates are opening on one of the biggest Personal Injury Protection (PIP) fraud schemes in Florida. Over the past 18 months, police have arrested more than 100 people — that’s an average of one every five days — on charges they participated in staged vehicle accidents.

Two of them were just sentenced. Jose Alberto Velez, 30, was ordered to spend six years and two months in prison, and  April Rosita Wynn, 23, was given four years. Both had been convicted in June for their roles in faking car accidents and filing false PIP claims with insurance companies.

Their arrests stemmed from an investigation begun in 2012 by the state attorney’s office and the Florida Division of Insurance Fraud. They found that Velez and Wynn recruited friends and family to participate in their scam. It involved orchestrating low-speed crashes of vehicles and having the occupants claim that they had suffered serious injuries that required medical treatment.

The individuals were directed to rehabilitation clinics which filed insurance claims for examinations and treatment not needed and sometimes not given. Participants were usually paid a small sum while the fraud masterminds received the bulk of the insurance payouts.

Investigators nabbed many people, including David Rodriguez Lopez, whom they consider to be the ringleader. He has been sentenced to 15 years in prison. He will likely have company; many more cases are pending.

Want your PIP benefits? Follow the rules — and the law

August 11th, 2014

When medical clinics sue auto insurance companies over unpaid Personal Injury Protection (PIP) claims, it seems that they win more times than not. The clinics’ attorneys also come out the victors, sometimes taking home more money than their clients.

And then there’s the case of Dr. Sara C. Vizcay and her seven medical clinics. She was paid nearly $1 million by an auto insurer who then sued her to recover. Not only did the insurer win back all the money, the jury awarded it $50,000 per clinic in damages. The good doctor appealed to the U.S. District Court for the Middle District of Florida in Tampa.

Things had not gone well at trial. According to the federal court’s opinion, the trial jury found that:

  • The PIP payments were not properly payable to the clinics due to fraudulent billing practices and failure to comply with the licensing
    requirements of the Florida Health Care Clinic Act.
  • The clinics misrepresented material facts.
  • Dr. Vizcay and each health care clinic committed fraud and were unjustly enriched.
  • Dr. Vizcay failed to comply with her medical director duty to systematically review the bills at the Medical Director Clinics, the clinics were operating contrary to Florida law.

Could it have gotten any worse? Actually, things turned out better than they could have for Dr. Vizcay. The appeals court upheld the jury’s decision to have her clinics repay the auto insurer nearly $950,000. However, she didn’t have to pay damages, she kept her license, and the clinics stayed open. You might want to note their names next time you need chiropractic attention:

  • Best Care Medical Center, Inc.
  • Caleb Health Care, Inc.
  • Florida Rehabilitation Practice, Inc.
  • Global Diagnostic Center, Inc.
  • Personal Medical Center, Inc.
  • P.V.C. Medical Center, Inc.
  • Regional Enterprises for Health Corporation

Another attempt to derail Florida PIP reforms fails in court

August 4th, 2014

As the saying goes, “If at first you don’t succeed, try, try again.” That’s what chiropractors are doing as they seek to undo Personal Injury Protection (PIP) reforms in Florida that working to reduce auto insurance fraud.

The latest effort, a state lawsuit, was dismissed. That followed an injunction in state court that was subsequently revoked by an appeals court. Who’s suing? Chiropractors and other businesses that financially benefited under the old rules. Of course, fraud was much worse before the new Florida PIP law took effect in July 2012.

The following March, acupuncturists, chiropractors and licensed massage therapists asked a Tallahassee circuit court judge to block a portion of the law that banned payments to them and that required a person seeking PIP benefits to seek  treatment within 14 days of an accident from a physician or hospital except under what are called Emergency Medical Conditions.

They won, but the 1st District Court of Appeals reversed the circuit court on Oct. 23. As we reported then, “The appeals court said the business groups failed to show a specific instance that supported their claim of denial of access to the courts. The court also said that the claim of economic harm was insufficient to assert the potential access-to-courts claims of other parties.”

The business groups were denied a rehearing in late November, but they didn’t give up. In September 2013, Accumed Chiropractic & Wellness Center sued Progressive Select Insurance in Miami-Dade circut court, seeking class-action status for two groups. According to the judge’s final order, they were:

  1. All persons who have submitted claims to Progressive under PIP and/or MedPay insurance coverage for services or care, where Progressive has denied payment either in whole or in part based on an assertion that an Emergency Medical Condition was not established for the injured insured.
  2. All persons who have submitted claims to Progressive under PIP and/or MedPay insurance coverage for services or care, where Progressive has denied payment because the health care service was for massage therapy and/or acupuncture.

The judge tossed the case on July 31, writing in an opinion that “the necessary and individualized questions associated with the underlying PIP claims of the class will predominate in this Action and render this Action inappropriate for class action treatment as a matter of law.”

Do we expect acupuncturists, chiropractors and licensed massage therapists to try again? Oh, yeah.


Florida PIP reform law withstands legal challenges on payments

July 28th, 2014

Can’t get what you want from Florida’s Personal Injury Protection (PIP) reform law? You could try suing your insurance company, but don’t expect good results.

Two individuals claimed in U.S. District Court for the Southern District of Florida that their auto insurers denied them proper PIP benefits. They both lost.


Glenaan Robbins went after her insurance company, claiming in a lawsuit that it violated a provision that that limits PIP benefits based on whether an emergency medical condition exists. The reform law tries to cut down on inflated claims by limiting the reimbursement to $2,500 if there was no emergency. The insurer must pay up to $10,000 if a qualified medical provider says there was an emergency.

Robbins was injured April 2013 and claimed in her lawsuit that “no determination was made that she did not have an emergency medical condition.” That’s a double negative for those of you that pay attention to grammar rules. The insurer disagreed and paid $2,500.

The court was not sympathetic to her argument. It ruled that there must be an emergency condition before an insured person can qualify for the higher PIP amount. Case dismissed.


Sendy Enivert also said her insurer erred by not paying $10,000 in PIP benefits. She argued that the $2,500 limit applies when a medical provider says there is no emergency. Because no medical provider said that the conditions were not met (There’s that double negative again.) she was entitled to the higher limit of $10,000.

Again, the court disagreed. “A medical provider did not determine that Enivert had an EMC [emergency medical condition], and she concedes that she did not have one. Therefore, Enivert is not entitled to the full $10,000 in benefits and her claim fails,” the court said in its opinion.

The court went a step further and recited statistics about the widespread problem of PIP fraud, especially in South Florida.

“The Court finds it clear that the legislative intent behind the PIP Statute is to decrease PIP fraud in Florida by placing more stringent requirements on the insured in order to receive the full amount of benefits and to efficiently allocate maximum benefits to the insured who have severe medical conditions. Therefore, the PIP Statute’s clear language and legislative intent are consistent,” the court wrote. Case dismissed.

Vehicle hit when you’re not in it? No problem, file a PIP claim

July 20th, 2014

Something strange happened to Frank Assouman one day. His parked truck was hit while he wasn’t in it, yet he filed Personal Injury Protection (PIP) claims totaling more than $25,000.

The Florida Division of Insurance thought it was odd, too, and arrested him. The state agency charged the 51-year-old West Palm Beach man with PIP fraud.

Assouman said he was eating lunch in his truck in Boca Raton when a vehicle struck his vehicle. The crash report and a witness statement disputed that.

He said that later  felt pain while on a trip to Haiti, according to an article in the Palm Beach Post. Assouman went to Delray Diagnostics for an MRI and Modern Medicine, Inc. for other treatment.

Those visits generated PIP claims of $21,815 to the other driver’s insurance company and $3,035 to his insurer. Both companies refused to pay, according to the Post article.


What do Florida PIP claimants like to do? Sue, sue, sue.

July 14th, 2014

If you are wondering where your Personal Injury Protection (PIP) premiums go, look no further than the courthouse. More than half of Florida individuals and clinics hire lawyers to pursue insurance claims.

Those attorneys charge $300 to $500 an hour to fill out paperwork and shuttle it to the clerk of court. The lawyers then ask county court judges to approve their legal bills and order insurance companies to pay them. Sometimes, the lawyers who say they are working for the little guy collect tens of thousands of dollars when the client is seeking is a few dollars.

The percentage of PIP claimants nationwide represented by attorneys rose to 36 percent in 2012 from 31 percent in 2007, according to a study by the Insurance Research Council. It comes as no surprise to us or another auto insurer that Florida leads the nation, where more than half of claimants hired attorneys in 2012.

“The attorney involvement trends shown in this study undercut two of the envisioned benefits of no-fault auto injury systems: a less adversarial settlement process and more timely payments,”  Elizabeth Sprinkel, senior vice president of the council said in a press release. “The role of attorneys is implicated in many of the factors driving up the cost of auto insurance.”

The study found that in cases where attorneys represented claimants that individuals were much more likely than those without a lawyer to receive treatment in a pain clinic and were more likely to be involved in apparent claim abuse.

PIP fraud investigations have found that people involved in staged accidents and other illegal efforts to cheat the PIP system signed over their benefits to the clinic that was supposedly diagnosing and treating them. The clinics hired attorneys to sue auto insurance companies when the claims were investigated and sometimes denied.

The study was part of the council’s continuing research into auto injury claims. More than 35,000 auto injury claims were examined and 12 insurers that represent 52 percent of personal driver market participated.



Protect yourself from PIP criminals by learning tricks of the trade

July 8th, 2014

Do you know the difference between a Curbed Drive Down and a Swoop and Squat? Have you heard of either one? If not, you could become a victim of Personal Injury Protection (PIP) fraud.

Staged-accident perpetrators often involve innocent people in their schemes. They move their vehicles in sudden ways that make a collision unavoidable. Their goal: Collect PIP benefits by claiming non-existent injuries.

You can avoid being caught in their plans by recognizing the kinds of traffic games they play. The National Insurance Crime Bureau has made several short videos of about 30 seconds each that show the driver moves that the PIP fraudsters like best. We’re posting them here as a public service.

The first is the Curbed Drive Down. Here are the rest:




Married couple finds that PIP crime doesn’t have happy ending

July 2nd, 2014

Jose Alberto Velez and April Rosita Wynn

The massive investigation called Operation Sledgehammer has won another two convictions on charges of Personal Injury Protection (PIP) fraud.

In the latest case, investigators in Duval County discovered that Alberto Velez, 30, and April Rosita Wynn, 23, enlisted family members and friends to participate in staged car accidents. The individuals claimed injuries and filed PIP claims through rehab clinics. The clinics billed auto insurance companies for treatment for non-existent injuries.

Velez and Wynn face up to 20 years in prison and have other charges pending, according to a press release from the state attorney’s office for the Fourth Judicial District in northeast Florida. They will be sentenced at the end of July.

The two, who are now married, were charged with knowingly participating in an intentional motor vehicle crash on May 12, 2012. Typically, this PIP fraud involves colliding two vehicles at low speed and having recruited participants enter them after the fact. When police arrive, the individuals complain of injuries.

Velez and Wynn were also convicted on four counts of false insurance claims. Typically, the stated-accident participants are directed to clinics where they sign over their PIP benefits. The clinic submits falsified medical and treatment reports and pockets the PIP payments.



Beware the kind driver: You could get caught in a PIP scam

June 30th, 2014


The scenario is simple: The other driver has the right of way but waves you on. You pull out and the other vehicle hits you. The driver and passengers immediately complain of injuries. Congratulations, you’ve been caught in a Personal Injury Protection (PIP) scam.

News4Jax has been covering the underhanded methods by which people stage auto accidents and collect PIP benefits. The Jacksonville news station is to be commended for its diligent work in exposing how criminals operate. Jodi Mohrmann, managing editor of special projects, has devoted a series to PIP abuses. The latest report shows how innocent drivers  were made liable for accidents they didn’t cause, and how auto insurance companies were ripped off for hundreds of thousands of dollars.

In one instance, a woman turned at a stop sign and another car hit her. The passengers of that vehicle said they had injured knees, necks and other body parts.

“All of a sudden they’re in this car accident and they have no idea how they got there because they were being waved on,” U.S. Postal Inspector Stephanie Barrett told News4Jax. Insurance losses totaled $180,000. Watch the video to learn more.

Operation Sledgehammer nails 3 more PIP fraud arrests

June 21st, 2014

From left, Leslie Martinez, Claudio Boyett and Claudia Hoy.

Operation Sledgehammer has been one of the most effective efforts in Florida history to root out Personal Injury Protection (PIP) fraud. Roughly 100 people in South Florida have been put in handcuffs since the four-year investigation began.

Add three more to the list. Claudio Boyett, 44, Leslie Martinez, 45, and Claudia Hoy, 31, all of Fort Lauderdale, face charges that they staged an accident and defrauded United Auto Insurance Co.

Based on police reports, the fraud scheme was a classic: Bump two vehicles and claim injures. In this instance, a U-Haul truck driven by Boyett struck a Dodge Caravan carrying seven people, including driver Martinez,  in a Fort Lauderdale church parking lot in August 2012.

The three people arrested had gone to a clinic for medical treatment for their faked injuries. The bills totaled $80,000.

Investigators learned that the van owner was offered $1,500 to borrow her vehicle, according to a Sun-Sentinel report. Another witness admitted the accident was staged.

This is just the latest chapter in Operation Sledgehammer, a four-year cooperative effort among federal, state and insurance industry investigators. As of late April, the U.S. Attorney’s Office had charged 57 people and obtained convictions or guilty pleas from 51 of them. Federal prosecutors had won court-ordered restitution of more than $11 million to defrauded insurance companies.

The Palm Beach County State Attorney’s Office had charged another 36 defendants.