Over the past several years, there has been steady increase in suits by automobile insurance carriers against health care providers who treat individuals in connection with their personal injury claims. Most of these suits allege that the health care providers are fraudulently billing the insurance companies by either billing for services that were not performed or by providing treatment to the patients that is not medically necessary. With rising insurance costs, this is a litigation trend that is likely to continue in the coming years.
For example, Allstate Insurance Corporation’s filed a $6 million suit targeting allegedly fraudulent Long Island no-fault health care providers. The company says the suit is part of a larger litigation strategy, which it contends will deter fraudulent billing by health care providers and spur changes to New York’s “fraud-riddled” system. Allstate has accused several health care providers and New York businesses of billing for services that were not performed or medically unnecessary, and of funneling money, in violation of state law, to a proprietor who was not legally allowed to profit from the health services.
In New York, insurers have pushed hard — so far unsuccessfully — for a law making staging accidents to reap no-fault money a felony crime, the ability to retroactively cancel policies involving staged accidents and a law putting the onus on medical care providers to prove that the care they give is medically necessary, among other reform measures. Critics of such proposals see them as attempts to increase profits even as insurers aggressively target those seeking benefits, under a policy that is supposed to allow for quick payments to address injuries while discouraging damages lawsuits.
Insurers scored a big win in 2005 in State Farm v. Robert Mallela when New York’s highest court ruled insurers “may look beyond the face of licensing documents to identify willful and material failure to abide by state and local law” in their pursuit of allegedly fraudulent care providers. Additionally, in Allstate Insurance v. David Mun, the Second Circuit held that an insurer may file a lawsuit based on allegations of fraud without first submitting the matter to arbitration.
Other insurers, such as State Farm, Liberty Mutual and Geico, have also filed similar suits against health care providers in many areas of the country. Providers in Pennsylvania, New Jersey and Delaware have also been sued by State Farm, Allstate and Geico, among other insurance companies. These cases can be expensive to litigate, and are extremely damaging to the providers’ business. When faced with one of these lawsuits, providers should check their insurance coverage, as some policies may cover some or all of the cost to defend against these lawsuits.
Posted On Friday, August 29, 2014
The Third Circuit has held that a criminal defendant who files an appeal after entering into a plea agreement in which the defendant agrees to waive his or her appellate rights may forfeit the benefits he or she received from the government in return for the guilty plea.
In United States v. Erwin, No. 13-3407 (3d Cir. August 26, 2014), Christopher Erwin pled guilty to conspiracy to distribute and possession with the intent to distribute oxycodone. As part of the plea agreement, Erwin waived the right to appeal his sentence if it was within or below the guidelines for a particular offense level. The government agreed not to bring further criminal charges against Erwin related to the conspiracy and to ask for a downward departure to Erwin’s sentence. During sentencing, the government complied with its obligations and Erwin was sentenced within the range in question. Erwin appealed arguing that the district court did not properly calculate the downward departure in arriving at the sentence and that he should have released a shorter prison term. The government responded to the appeal by arguing that Erwin had breached the appellate waiver, that his sentence should be vacated and that the case should be remanded for resentencing.
The Third Circuit initially determined that Erwin’s appeal fell within the scope of the appellate waiver. The court went on to note that while it would normally simply dismiss the appeal, the government had argued that this was not enough because it had been forced to commit resources to litigating an appeal that should not have been filed. The government also stated that dismissal, alone, would not deter other criminal defendants from breaching their plea agreements. In analyzing this issue, the court found that Erwin had clearly violated the agreement. The court went on to note that the criminal justice system depended upon plea agreements and that they had to be enforced in order to maintain the integrity of the process. A new sentencing was said to be feasible because Erwin’s plea agreement specifically stated that the government would not be required to ask for a downward departure if Erwin violated any provisions in the agreement. In light of these factors, the Third Circuit concluded that Erwin’s sentence would be vacated, that he would be resentenced and that the government would be released from its earlier promise to ask for a downward departure during the re-sentencing process.
It is unclear to what extent the Third Circuit’s decision depended upon the fact that there was language in the plea agreement stating that the government did not have to comply with its obligations if Erwin failed to abide by all of the terms of the agreement. However, in light of Erwin, it is anticipated that the government will be including these types of provisions in future plea agreements.
Erwin did not change the established principle that appellate waivers will not be enforced if the criminal defendant did not knowingly and voluntarily give up his or her right to appeal, if the issues raised on appeal do not fall within the scope of the waiver or if enforcement of the waiver would result in a miscarriage of justice. However, the Erwin court made it clear that a criminal defendant who decides to pursue an appeal despite the existence of such a waiver must accept the risk that dismissal of the appeal might not be the only consequence he or she faces if the appeal is not successful.
