Justia White Collar Crime Opinion Summaries

A group of insurance companies sued various medical providers and related individuals in federal court, alleging that the providers engaged in a fraudulent scheme in violation of the Racketeer Influenced and Corrupt Organizations Act (RICO). Specifically, the insurance companies claimed that the defendants submitted fraudulent reports and billing documents for patients involved in car accidents, seeking payments under insurance policies. The allegations included overbilling, billing for services not rendered, and unnecessary procedures.After the insurance companies filed their initial complaint in the United States District Court for the Southern District of Texas, the parties held several conferences to address potential deficiencies. Defendants argued that the complaint failed to adequately allege the existence of a RICO “enterprise,” particularly a consensual decision-making structure among the alleged participants. The insurance companies amended their complaint, but the defendants again moved to dismiss, challenging the sufficiency of the RICO allegations. The magistrate judge recommended granting dismissal due to the complaint’s failure to plead an adequate enterprise. The district court agreed, granting dismissal but allowing the plaintiffs to file a post-judgment motion to amend.On appeal, the United States Court of Appeals for the Fifth Circuit reviewed whether the district court erred in denying leave to further amend the complaint after judgment. The appellate court held that even though the district court referenced the Rule 59(e) standard rather than the more liberal Rule 15(a) standard for amendment, it was appropriate to affirm if there were “ample and obvious” reasons for denial, such as undue delay. The Fifth Circuit found that the insurance companies had delayed seeking amendment and stood by their pleading’s sufficiency despite repeated notice of its deficiencies, and thus, the district court did not abuse its discretion in denying leave to amend. The judgment was affirmed. View "Farmers Texas County Mutual Insurance Co. v. 1st Choice" on Justia Law

Chang Goo Yoon, a licensed physical therapist operating clinics in Massachusetts, engaged in a scheme over four years to submit more than one million dollars in fraudulent claims to private health insurers, including Blue Cross Blue Shield and Aetna, for services he did not actually provide. He fabricated treatment notes, sometimes under another provider's name, and submitted false personal injury claims to his own car insurer, MAPFRE. Yoon manipulated patient addresses to ensure reimbursement checks were sent directly to him, avoiding detection by patients. His fraudulent conduct was eventually uncovered, and a jury convicted him on two counts of health care fraud, with Count One involving Blue Cross and Aetna, and Count Two concerning MAPFRE.The United States District Court for the District of Massachusetts presided over the trial. Before trial, Yoon moved to exclude evidence related to insurance company investigations into his billing, including a 2015 Blue Cross investigation and a 2007 Colorado licensing investigation. The district court limited the evidence to Yoon’s knowledge of the investigations, excluding their outcomes. The court also redacted key documents and provided limiting instructions to the jury. At trial, witnesses testified about insurance procedures and Yoon’s billing practices. Yoon challenged the admissibility of this evidence, as well as testimony from insurance investigators, arguing it was unduly prejudicial and improperly admitted.The United States Court of Appeals for the First Circuit reviewed Yoon’s appeal. The court affirmed the district court’s evidentiary rulings, holding that evidence of Yoon’s knowledge of prior investigations was highly probative of his specific intent and not unduly prejudicial given the safeguards imposed. The court also affirmed the application of two sentencing enhancements: one for intended loss based on the total amount billed, and another for abuse of a position of trust, finding both were supported by the record and correctly applied. Yoon’s conviction and sentence were affirmed. View "United States v. Yoon" on Justia Law

GEICO and its subsidiaries brought a lawsuit in the United States District Court for the Eastern District of New York against Dr. Bhargav Patel and his medical practice, alleging that the defendants engaged in a scheme to defraud GEICO by manipulating New York’s no-fault automobile insurance system. GEICO claimed that from 2019 to 2023, defendants submitted approximately $3.4 million in reimbursement claims for treatments that were unnecessary, experimental, excessive, illusory, or not provided at all. These claims allegedly resulted from a fraudulent scheme involving kickbacks for patient referrals and the provision of services by unlicensed individuals or contractors.After GEICO initiated its federal action, the defendants responded by filing over 600 collection actions in New York state courts and arbitration tribunals, seeking recovery for disputed or denied claims totaling more than $2 million. GEICO, facing the prospect of fragmented litigation and the risk of inconsistent judgments, sought a preliminary injunction from the district court to stay all pending state and arbitration proceedings and to prevent the defendants from filing new collection actions until the federal court resolved the RICO claims. The district court granted the injunction, finding that GEICO had demonstrated irreparable harm, serious questions going to the merits, and a balance of hardships tipping in GEICO’s favor. The court also determined it had authority under the “in aid of jurisdiction” exception to the Anti-Injunction Act to enjoin the parallel proceedings.On appeal, the United States Court of Appeals for the Second Circuit reviewed the district court’s decision for abuse of discretion and found none. The appellate court held that the preliminary injunction was justified by the real risk of irreparable harm to GEICO posed by inconsistent judgments and the inability to fully adjudicate the alleged fraudulent scheme in piecemeal state actions. The Second Circuit further held, consistent with its recent precedent in State Farm Mutual Automobile Insurance Company v. Tri-Borough NY Medical Practice, P.C., that the injunction did not violate the Anti-Injunction Act because it was expressly authorized under RICO. The court affirmed the district court’s order. View "GEICO v. Patel" on Justia Law

Several entities affiliated with Allstate sued a group of individuals and entities that own, manage, and operate Memorial Heights Emergency Center in Houston, Texas. The plaintiffs alleged that, starting in 2018, defendants entered into agreements with personal injury attorneys to refer clients to the Center under letters of protection, guaranteeing future payment from insurance settlements. Defendants billed these patients—primarily car accident victims—using emergency billing codes at rates far above standard charges, often conducting expensive diagnostic tests without documented medical necessity and discharging patients without additional treatment. The bills were then sent to attorneys, who submitted them to Allstate for inclusion in settlement demands. Between August 2018 and November 2022, Allstate settled with 635 claimants and subsequently alleged it discovered a fraudulent scheme, seeking to recover $4.7 million plus treble damages and attorney fees.The United States District Court for the Southern District of Texas dismissed all claims with prejudice. The district court held that Allstate failed to sufficiently allege reliance on the fraudulent bills, undermining its RICO, common-law fraud, conspiracy, unjust enrichment, and money-had-and-received claims. The court also found Allstate had not adequately pleaded direct or proximate causation, concluded that Allstate was “complicit” in the alleged fraud due to its continued settlements after learning of the scheme, and determined that the complexity of the case made it unmanageable as a single lawsuit.On appeal, the United States Court of Appeals for the Fifth Circuit reviewed the dismissal de novo. The Fifth Circuit held that the district court applied the wrong legal standards to Allstate’s RICO claims by requiring reliance, which is not necessary for a RICO claim predicated on mail fraud. The appellate court further found that Allstate adequately pleaded proximate cause, damages, and the elements of its common-law and equitable claims. The judgment of the district court was reversed and the case remanded for further proceedings. View "Allstate Indemnity Co v. Bhagat" on Justia Law

Lawrence Rudolph was convicted for the fatal shooting of his wife, Bianca Rudolph, during a 2016 hunting trip in Zambia. The couple, married for nearly thirty-five years, had substantial marital assets and maintained significant life insurance policies. Their marriage was troubled by infidelity, including Mr. Rudolph’s long-term affair with Lori Milliron, a partner at his dental practice. After Bianca’s death, which Mr. Rudolph claimed was accidental, he collected nearly $4.8 million in life insurance proceeds and purchased several high-value assets. Less than two weeks after returning to the United States, he arranged for Ms. Milliron to join him in Arizona, and they began living together.The Federal Bureau of Investigation in Denver initiated an investigation in 2019, reviewing the Zambian authorities’ findings and conducting its own forensic analysis. In December 2021, Mr. Rudolph was arrested in Denver after being deported from Mexico, and indicted by a grand jury in the United States District Court for the District of Colorado on charges of foreign murder and mail fraud. He moved to dismiss for improper venue and to sever his trial from Ms. Milliron’s, arguing that the government engaged in forum shopping and that a joint trial would prejudice his defense. The district court denied both motions, admitted certain statements by Bianca under the forfeiture-by-wrongdoing exception, and ordered forfeiture of assets purchased with the insurance proceeds.The United States Court of Appeals for the Tenth Circuit reviewed the case. It held that venue in Colorado was proper under 18 U.S.C. § 3238, as Mr. Rudolph was both “arrested” and “first brought” to the district in connection with the charges. The court found no abuse of discretion in denying severance, admitting Bianca’s statements under Rule 804(b)(6), or ordering forfeiture of the assets, including interest and appreciation. The Tenth Circuit affirmed the district court’s judgment and forfeiture order. View "United States v. Rudolph" on Justia Law

Conduent State Healthcare, LLC (Conduent) was hired by the State of Texas to administer its Medicaid program. In 2012, Texas began investigating Conduent for allegedly helping orthodontics offices overbill for services. Texas sued several orthodontic providers in 2014, and the providers sued Conduent. Texas terminated its contract with Conduent and sued Conduent under the Texas Medicaid Fraud Prevention Act. Conduent was insured by AIG Specialty Insurance Company, ACE American Insurance Company, and Lexington Insurance Company, among others. The insurers provided defense coverage for the provider actions but denied coverage for the state action, claiming it involved fraudulent conduct excluded by the policies.The Superior Court of Delaware found that the insurers breached their duty to defend Conduent in the state action. The court also ruled that Conduent was relieved of its duties to cooperate and seek consent before settling with Texas due to the insurers' breach. The jury found that Conduent acted in bad faith and fraudulently arranged the settlement but did not collude with Texas or settle unreasonably. The Superior Court granted a new trial due to evidentiary issues and the jury's inconsistent verdicts.The Supreme Court of Delaware affirmed the Superior Court's rulings. It held that the insurers' breach of their duty to defend excused Conduent from its duties to cooperate and seek consent. The court also ruled that the policy's fraud exclusion did not bar indemnity coverage because the settlement was allocated to breach of contract damages. The court found that the evidentiary issues and the jury's inconsistent verdicts justified a new trial to prevent manifest injustice. View "AIG Specialty Insurance Company v. Conduent State Healthcare, LLC" on Justia Law

Julian Omidi and his business, Surgery Center Management, LLC (SCM), were involved in a fraudulent scheme called "Get Thin," which promised weight loss through Lap-Band surgery and other medical procedures. Omidi and SCM defrauded insurance companies by submitting false claims for reimbursement, including fabricated patient data and misrepresented physician involvement. The scheme recruited patients through a call center, pushing them towards expensive medical tests and procedures regardless of medical necessity.A grand jury indicted Omidi and SCM for mail fraud, wire fraud, money laundering, and related charges. After extensive pretrial litigation and a lengthy jury trial, both were convicted on all charges. The district court sentenced Omidi to 84 months in prison and fined SCM over $22 million. The government sought forfeiture of nearly $100 million, arguing that all proceeds from the Get Thin scheme were derived from fraud. The district court agreed, finding that even proceeds from legitimate procedures were indirectly the result of the fraudulent scheme.The United States Court of Appeals for the Ninth Circuit reviewed the case. The court affirmed the district court's forfeiture judgment, holding that under 18 U.S.C. § 981(a)(1)(C), all proceeds directly or indirectly derived from a health care fraud scheme must be forfeited. The court rejected the argument that only proceeds from fraudulent transactions should be forfeited, noting that the entire business was permeated with fraud. The court concluded that there is no "100% Fraud Rule" in forfeiture cases seeking proceeds of a fraud scheme, and all proceeds from the Get Thin scheme were subject to forfeiture. View "United States V. Surgery Center Management, LLC" on Justia Law

State Farm Mutual Automobile Insurance Company and State Farm Fire and Casualty Insurance Company (collectively, “State Farm”) provide automobile insurance in New York and are required to reimburse individuals injured in automobile accidents for necessary health expenses under New York’s No-Fault Act. State Farm alleges that several health care providers and related entities engaged in a scheme to fraudulently obtain No-Fault benefits by providing unnecessary treatments and services, and then pursued baseless arbitrations and state-court proceedings to seek reimbursement for unpaid bills.The United States District Court for the Eastern District of New York granted State Farm’s motion for a preliminary injunction in part, enjoining the defendants from proceeding with pending arbitrations and from initiating new arbitrations and state-court proceedings, but denied an injunction of the pending state-court proceedings. The district court found that State Farm demonstrated irreparable harm due to the fragmented nature of the proceedings, which obscured the alleged fraud, and the risk of inconsistent judgments and preclusive effects.The United States Court of Appeals for the Second Circuit reviewed the case and affirmed the district court’s decision to grant the preliminary injunction in part. The appellate court held that the district court did not abuse its discretion in finding that State Farm demonstrated irreparable harm, serious questions going to the merits, a balance of hardships tipping in its favor, and that the injunction was in the public interest. The court also concluded that the Federal Arbitration Act did not bar the injunction of the arbitrations because the arbitrations would prevent State Farm from effectively vindicating its RICO claims.Additionally, the appellate court reversed the district court’s decision not to enjoin the pending state-court proceedings, finding that the Anti-Injunction Act’s “expressly-authorized” exception applied. The court determined that the state-court proceedings were part of a pattern of baseless, repetitive claims that furthered the alleged RICO violation, and that enjoining these proceedings was necessary to give RICO its intended scope. The case was remanded for further proceedings consistent with this opinion. View "State Farm Mutual v. Tri-Borough" on Justia Law

After defendants Frayba and William Tipton pled guilty to committing insurance fraud, they were ordered to pay victim restitution to Nationwide Insurance Company of America (Nationwide). Later, Nationwide petitioned the trial court to convert the criminal restitution orders to civil judgments against both defendants. Defendants opposed. Relying on Penal Code1 section 1214, the trial court granted Nationwide’s petition and entered civil judgments against the defendants. On appeal, defendants argued the trial court erred because (1) Nationwide “failed to provide citation to any . . . authority supporting” conversion of the victim restitution orders to civil judgment; and (2) Nationwide’s petition lacked supporting evidence. The Court of Appeal found no reversible error and affirmed the trial court's judgment. View "Nationwide Ins. Co. of Am. v. Tipton" on Justia Law

The issue this case presented for the New Jersey Supreme Court's consideration was whether claims brought under the Insurance Fraud Protection Act (IFPA) and the Workers’ Compensation Act (WCA) by plaintiffs Liberty Insurance Corp. and LM Insurance Corp. (Liberty) against defendants Techdan, LLC (Techdan), Exterior Erecting Services, Inc. (Exterior), Daniel Fisher, Robert Dunlap, and Carol Junz were subject to the apportionment procedure of the Comparative Negligence Act (CNA). Liberty issued workers’ compensation policies to Techdan from 2004 to 2007. It alleged defendants misrepresented the relationship between Techdan and Exterior and the ownership structure of the two entities and provided fraudulent payroll records to reduce the premiums for workers’ compensation insurance. Techdan was indicted for second-degree theft by deception, and Dunlap entered a guilty plea to that charge on Techdan’s behalf. The court granted partial summary judgment as to Liberty’s IFPA claim for insurance fraud against Techdan, Exterior, Dunlap, and Fisher; partial summary judgment as to Liberty’s workers’ compensation fraud claim against all defendants; and partial summary judgment as to Liberty’s breach of contract claim against Techdan and Exterior. The court denied summary judgment as to Liberty’s remaining claims. The jury found Techdan liable for $454,660 in compensatory damages and found Exterior liable for $227,330 in compensatory damages, but awarded no compensatory damages against Dunlap, Fisher, or Junz. It awarded punitive damages in the amount of $200,000 against Dunlap, $10,000 against Fisher, and $45,000 against Junz, but awarded no punitive damages against Techdan or Exterior. The trial court determined all defendants should be jointly and severally liable for the $756,990 awarded as compensatory damages. The Appellate Division held the trial court erred when it imposed joint and several liability on defendants rather than directing the jury to allocate percentages of fault to defendants in accordance with N.J.S.A. 2A:15-5.2(a)(2). The Division concluded the trial court’s cumulative errors warranted a new trial, and it remanded for further proceedings. The Supreme Court concurred with the appellate court: the trial court should have charged the jury to allocate percentages of fault and should have molded the judgment based on the jury’s findings; the trial court’s failure to apply the CNA warranted a new trial on remand. The Court did not disturb the first jury’s findings on the issues of liability under the IFPA, the WCA, or Liberty’s common-law claims, or its determination of total compensatory damages. The Court found no plain error in the trial court’s failure to give the jury an ultimate outcome charge. View "Liberty Insurance Corp. v. Techdan, LLC" on Justia Law