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Fraud/Special Investigation

Insurance fraud costs insurers and consumers more than $300 billion dollars annually. Backed by decades of SIU experience, our Fraud/Special Investigation Practice Group is built for one purpose: to identify, confront, and eliminate fraud at every level. As fraud schemes become more sophisticated and organized, our team delivers an aggressive legal strategy and courtroom strength required to meet that challenge head-on.

We do not take a passive approach. We partner with insurers and self-insured entities to investigate aggressively, litigate decisively, and pursue recovery wherever fraud is uncovered. From inflated claims to large-scale fraud rings, wherever fraud is identified, we act swiftly, strategically, and without compromise.

Our trial attorneys are seasoned litigators with a deep understanding of how fraud schemes operate and how to dismantle them. We routinely initiate affirmative litigation and secure judgments against claimants, insureds, and medical providers engaged in fraudulent conduct.

Our involvement extends beyond the courtroom. Through active participation in leading organizations such as the National Insurance Crime Bureau (NICB), the International Association of Special Investigation Units (IASIU), the Coalition Against Insurance Fraud and others, our attorneys stay ahead of emerging threats and evolving tactics. That knowledge translates into stronger, smarter strategies for our clients.

Our vast experience includes matters involving:

  • Medical provider fraud
  • RICO
  • Staged accidents
  • Trucking losses
  • New York Labor Law and premises actions
  • Claimant fraud
  • Workers' compensation fraud
  • Vehicle "give ups"
  • Insurance claim inflation
  • Arson and water damage

We believe the most effective fraud defense is an aggressive, offensive strategy. Our team leverages data-driven insights, advanced investigative techniques, and streamlined claims processes to detect fraud early, before losses escalate. We also consult nationally to help clients reduce claim leakage, strengthen internal protocols, and build more resilient anti-fraud programs.

Insurance fraud is not the cost of doing business; it is a direct attack on our clients’ bottom line.  At Marshall Dennehey, we treat it that way.

Results

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Dismissal Obtained in a Fraudulent Claim Matter

We secured the dismissal of a fraudulent claim against our insurance carrier client in a New York No-Fault/PIP Action. We argued the medical provider’s assignor was involved in a staged loss/fraudulent accident in order to obtain No-Fault/PIP benefits. In support of the defense, an SIU affidavit and the transcript of an Examination Under Oath (EUO) from the assignor were submitted, which included facts that casted doubt on the legitimacy of the accident. These included details such as the lack of an official police report, the insurance policy having been purchased right before the accident, and the inability of the assignor to remember key details of the accident. After a successful argument at the arbitration, the arbitrator ruled in favor of our client.

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Legal Update for Fraud/Special Investigation

SIU Gets a Boost: NJ Supreme Court Affirms Insurers' Right to Litigate, Not Arbitrate, Fraud Claims

July 21, 2026

In a significant win for insurers' Special Investigation Units, the New Jersey Supreme Court clarified that statutory insurance fraud and racketeering claims may proceed in court rather than through PIP arbitration. At issue was whether insurance fraud claims brought under New Jersey's Insurance Fraud Prevention Act (IFPA) and the state's Anti-Racketeering Act (NJ RICO) are subject to mandatory arbitration under the Automobile Insurance Cost Reduction Act’s (AICRA) PIP dispute-resolution framework. Allstate had sued a network of medical practices, physicians, and related corporate entities, alleging a scheme to extract more than $1.7 million in PIP benefits through fraudulent and misleading billing. The trial court dismissed Allstate's complaint and compelled arbitration, reading AICRA's arbitration clause — which covers "any dispute regarding the recovery of... benefits" under PIP coverage, N.J.S.A. 39:6A-5.1(a) — as sweeping in fraud and racketeering claims along with routine benefit disputes. The Supreme Court affirmed the Appellate Division's reversal, adopting Judge Gilson's opinion below (480 N.J. Super. 566 (App. Div. 2025)) as its own reasoning. The Court held that IFPA and RICO claims fall outside the scope of AICRA's PIP arbitration mechanism because that "streamlined and specialized" process cannot grant the relief those statutes contemplate — treble damages, injunctive relief, broad discovery, and joinder of third parties — and because arbitrators lack authority to award compensatory or treble damages to an insurer. The Court also rejected the argument that Allstate's own Decision Point Review Plans independently compel arbitration, finding those plan provisions no broader than AICRA's own arbitration clause. Notably, the Court expressly disagreed with the Third Circuit's contrary holding in GEICO v. Mt. Prospect Chiropractic Center, 98 F.4th 463 (3d Cir. 2024), concluding it is not bound by that federal interpretation of New Jersey law. Insurers retain the right to pursue IFPA and RICO claims in the Law Division, with a jury trial. For SIU units and NJ insurance carriers, this decision is a significant win: it forecloses defense clinics' primary procedural tool for shunting fraud investigations into limited-scope PIP arbitration, where treble damages, RICO relief, and meaningful discovery were never realistically available. Carriers building cases against fraudulently structured clinics, straw-owned practices, or coordinated billing networks can now proceed with confidence that a well-pleaded IFPA/RICO complaint stays in the Law Division rather than being diverted to arbitration on a motion to compel. Practically, this strengthens SIU's leverage in settlement negotiations, preserves civil discovery tools (subpoenas, depositions, joinder of related corporate entities) critical to unwinding complex ownership and referral schemes, and resolves the split with the Third Circuit in favor of NJ insurers — at least as a matter of state law. Expect increased reliance on IFPA civil actions, rather than PIP arbitration demands, as SIU's primary enforcement vehicle going forward.

Defense Digest

A Tale of Two Departments: Can a Motor Vehicle Defendant Assert Counterclaims Sounding in Fraud in Actions Involving Staged Accidents in Matters Venued in the Second and First Departments of the New York Appellate Division?

June 30, 2026

Key Points: The Second and First Departments of the New York Appellate Division have recently issued divergent decisions affecting a defendant’s entitlement to leave to amend its answer to assert counterclaims sounding in fraud where it appears that the accident at issue was staged/intentionally caused by the plaintiff depending on where the matter is venued. Based on these recent decisions, a defendant in a matter venued in a court in the Second Department is entitled to leave to amend its answer to assert counterclaims sounding in fraud based on mere allegations that the accident at issue was staged/intentionally caused by the plaintiff, the plaintiff knowingly made false representations to assert claims against the defendant, and that the defendant suffered damages consisting of its costs and fees incurred in investigating and litigating plaintiff’s claims.  However, a defendant in a matter venued in a court in the First Department is only entitled leave to amend its answer to assert counterclaims sounding in fraud where it submits prima facie evidence that the plaintiff staged/intentionally caused the accident and made false representations, and where the defendant alleges damages beyond those associated with its costs and fees incurred in investigating and litigating plaintiff’s claims. The Second and First Department of the New York Appellate Division both recently issued decisions addressing a defendant’s entitlement for leave to amend its answer to assert counterclaims sounding in fraud arising from an accident that is apparently staged and/or intentionally caused by a plaintiff. Specifically, despite the underlying similarities between Gimenez v. Pepsi-Cola Bottling Company of New York, Inc., 225 N.Y.S.3d 691 (NY 2d Dept. 2025) and Anguisaca-Morales v. St. Paul and St. Andrew United Methodist Church, 234 N.Y.S.3d 42 (NY 1st Dept. 2025), the respective decisions of the Second Department and First Department substantially diverged. As a result of these contrasting decisions, the venue of a matter will affect a defendant’s ability to successfully obtain leave to amend its answer to assert counterclaims sounding in fraud against a plaintiff.   Both Gimenez and Anguisaca-Morales involved plaintiffs whose alleged injuries resulted from accidents where liability would normally and presumably be decided against the defendants. In Gimenez, the plaintiffs allegedly were injured due to their vehicle being rear-ended by the defendants’ vehicle. In Anguisaca-Morales, the plaintiff allegedly fell from an unsecured ladder while working at a construction site. Both actions involved appeals from lower court decisions on the plaintiffs’ motions for summary judgment on liability and the defendants’ corresponding motions for leave to amend their answers to assert counterclaims for fraud against the plaintiffs based on allegations that the accident was staged/intentionally caused by the plaintiffs. With respect to the motions for summary judgment on liability, the Second and First Department both found issues of fact resulting in the plaintiffs not being entitled to summary judgment on liability. In Gimenez, the Second Department found that the defendants raised issues of fact as to the existence of a non-negligent explanation for the alleged accident and whether the plaintiffs staged the accident. In Anguisaca-Morales, the First Department found there were issues of fact as to whether the plaintiff intentionally fell and was the sole proximate cause of his alleged accident. Turning to the respective motions for leave to amend their answers filed by the defendants in Gimenez and Anguisaca-Morales, the defendants in both actions submitted proposed amended answers that asserted similar allegations of fraud in support of their respective counterclaims, including that: 1) the respective plaintiffs staged/intentionally caused the accidents; 2) that the respective plaintiffs knowingly made false representations against the respective defendants; and 3) that the respective defendants suffered damages as a result, consisting of incurring investigation and legal costs and fees. In both cases, the Second and First Department also reviewed evidence that they respectively determined had been sufficient to raise a question of fact as to whether the respective plaintiffs intentionally caused their accidents. However, despite the above similarities, the reasonings in these decisions regarding the respective defendants’ entitlement to leave to amend their answers diverged. In Gimenez, the Second Department held that the defendants were entitled to leave to amend their answer because the allegations asserted in their proposed amended answer were sufficient on their face to plead a counterclaim for fraud. However, in Anguisaca-Morales, the First Department held that the defendants were not entitled to leave to amend their answer because their proposed amended answer failed to sufficiently plead a counterclaim for fraud. In doing so, the First Department held that the counterclaim asserted in defendants’ proposed amended answer was premised on unproven allegations and the defendants failed to plead justifiable reliance or resulting damages. Thus, based on the Second Department’s decision in Gimenez, a defendant in an action venued in any of the lower courts in the ten counties that comprise the Second Department (Kings, Queens, Richmond, Nassau, Suffolk, Westchester, Dutchess, Orange, Rockland, and Putnam) is entitled to leave to amend its answer to assert a counterclaim for fraud against a plaintiff in an action based on mere allegations that the plaintiff staged and/or intentionally caused the accident at issue. Conversely, pursuant to the First Department’s decision in Anguisaca-Morales, a defendant in an action venued in any of the lower courts in the two counties that comprise the First Department (New York and Bronx) is not entitled to leave to amend its answer to assert a counterclaim for fraud against a plaintiff based on similar allegations. Even when the defendants submits evidence that that the plaintiff intentionally caused the accident that is sufficient to defeat a motion for summary judgment on liability. Instead, in order to be entitled to leave to amend its answer to assert a counterclaim for fraud against the plaintiff in a matter venued in the First Department, a defendant is effectively required to make a prima facie demonstration that the plaintiff staged/intentionally caused the accident and that the defendant sustained damages. In doing so, the damages must be in addition to what the defendant incurred in relation to investigating and litigating the plaintiff’s claims. The decisions in Gimenez and Anguisaca-Morales have not yet been cited in any subsequent decisions involving cases where the plaintiff allegedly staged/intentionally caused the accident. Instead, these decisions have only been discussed in multiple decisions by one judge in the New York Supreme Court, Kings County, in cases that do not involve allegations of staged accidents. This judge has inserted identical language in five decisions that appear to be a concerted attempt to limit the application of Gimenez to cases where there is “concrete evidence” that the accident was staged. Ian works in our Melville, NY office. He can be reached at (631) 227-6389 or ILGlick@mdwcg.com.

News

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Firm Highlights

Marshall Dennehey Named a Standout in Litigation by BTI Consulting Group

News

Marshall Dennehey Named a Standout in Litigation by BTI Consulting Group

Event

CLM 2026 Focus Conference

Allison joins three insurance industry leaders to discuss how cyber coverage disputes, the growing impact of social inflation on bodily injury claim valuation, and the use of artificial intelligence are reshaping the bad faith landscape. The panel will examine emerging sources of extra-contractual exposure, including evolving cyber insurance coverage issues and the challenges of accurately valuing bodily injury claims. Practical approaches to claim evaluation using AI, along with defense strategies designed to help prevent or successfully defend against bad faith litigation, will also be addressed. 

Bret E. Dubbert Joins Marshall Dennehey’s Orlando Office as Special Counsel in the Casualty Department

News

Bret E. Dubbert Joins Marshall Dennehey’s Orlando Office as Special Counsel in the Casualty Department

Result

$19 Million Medical Malpractice Verdict Overturned

In this medical malpractice case, the trial court vacated $10 million of a $19 million verdict in post-trial motions and the Superior Court of Pennsylvania vacated the remaining $9 million on appeal.

graphic announcing our 6 2027 Super Lawyers & Rising Stars

News

Marshall Dennehey Announces 2027 New Jersey Super Lawyers And Rising Stars

Result

Statutory Employer Immunity Upheld

In this construction accident case that resulted in a $5 million verdict, the Supreme Court of Pennsylvania upheld the Statutory Employer Doctrine, which immunizes general contractors and other contractors on construction sites when certain elements are satisfied.

Result

$1.09 Billion Products Liability Verdict Overturned

In this products liability crashworthiness case, the Superior Court of Pennsylvania reversed a Philadelphia jury verdict of $1.09 billion, the largest verdict ever overturned by a PA appellate court.  The court ordered a new trial based on deficient jury instructions, clarified important aspects of crashworthiness law, and confirmed that so-called standard jury instructions may be incompatible with Pennsylvania law. 

Thought Leadership

United State District Court for the Middle District of Florida finds Evidence of Replacement Cost Value is Admissible and Recoverable Even When Repairs Have Not Been Made

The plaintiff filed a claim for damage as a result of Hurricane Ian. It claimed damages were over $24 million, but the carrier accepted partial coverage and paid $8,307.49 for secondary components. The carrier found hurricane damage to the building, but it was below the insurance policy’s $3.6 million deductible. The plaintiff sued for breach of the insurance policy. The carrier argued in a motion for summary judgment that plaintiff could not recover replacement cost value (RCV) because the property repairs had not been effectuated. The policy provided for RCV, but only after the repairs were completed. The carrier argued that because the repairs were not completed, the plaintiff was not entitled to RCV damages. The plaintiff argued the carrier could not withhold the actual cost value (ACV) due, which was the main allegation of the lawsuit, then fault it for not making the repairs to unlock the RCV. The United States District Court for the Middle District of Florida rejected the carrier’s argument, finding that when an insurer allegedly breached the policy by withholding coverage, it could not hide behind a repair-contingent provision to block the insured from RCV damages at trial. The court found the issue to be whether the contractual language designed to preclude certain coverage until after repairs are completed barred an insured from seeking those damages at trial when repairs were not complete. The court noted the Eleventh Circuit had not resolved this issue and neither side pointed to a definitive answer from the Florida Supreme Court. The court reasoned that it must look to the Sixth District Court of Appeal (6th DCA), which is the court which would have heard this case if it was in state court. The court noted the 6th DCA recently addressed this issue in Universal Prop. & Cas. Ins. Co. v. Rodriguez, 427 So. 3d 676 (Fla. 6th DCA 2026). The Rodriguez Court found that a breach of contract action is designed to adjudicate not only whether the contract was breached, but also evaluate the damages incurred had the breach not occurred, which the Rodriguez court found to be recovery of the RCV. This court also noted basic Florida contract principles compelled the same result, as a material breach frees the nonbreaching party to suspend its own performance and can demand the full benefit of its bargain, including RCV damages. Finally, the court found the distinction between a full denial and partial denial did not compel a different result. It found the policy required the carrier to acknowledge coverage and pay ACV for all covered damages, and the failure to do that is a material breach, entitling the insured to all of the damages available under the contract, which included the RCV.

Thought Leadership

Appeals Court Reverses Trial Court Order Awarding Attorney’s Fees Due to Lack of Evidence to Support Fee Awarded

The Fourth District Court of Appeal reversed the trial court’s order awarding appellate fees to People’s Trust Insurance Company based upon a lack of evidence to support the attorney’s fee award in RM & Assocs. Consulting, Inc. v. People's Trust Ins. Co., 2026 Fla. App. LEXIS 4654 (Fla. 4th DCA 2026). People’s Trust was the insurer of a residential property that had sustained water damage. RM & Associates Consulting was hired by the homeowner to perform mitigation services at the property. The homeowner assigned post-loss benefits to RM and RM subsequently filed suit against People’s Trust alleging that it had not been paid the money it was owed for the mitigation services. People’s Trust defended the lawsuit on the ground that the policy required the insured to notify the insurer before authorizing repairs so People's Trust could elect to use its preferred contractor. Because the owner did not comply with that provision, People's Trust asserted its liability was limited to the amount that its preferred contractor would have charged for the work, which People's Trust contended was $2,000. People's Trust paid that amount to RM before RM filed suit. People’s Trust filed a motion for summary judgment which was granted. RM appealed the summary judgment ruling and the ruling was upheld by the Fourth District Court of Appeal. The appellate court also granted People’s Trust’s entitlement to appellate attorney’s fees, subject to the trial court’s determination of the amount of fees, based upon an offer of judgment made by People's Trust. On remand, the trial court held an evidentiary hearing to determine the amount of attorney’s fees People’s Trust was entitled to. At the hearing, People’s Trust presented testimony from it’s fee expert, supervising trial counsel and appellate counsel. People’s Trust sought recovery of $24,866.17 for work performed by appellate counsel. The request primarily consisted of work performed in preparation of the answer brief. The fee expert testified that more than ninety hours spent preparing the answer brief was reasonable given the complexity and significance of the underlying issue. The appellate court found that the fee expert’s testimony fell short of meeting the necessary standard of demonstrating that the hours expended were necessary. The appellate court found that the billing records did not serve to cure the deficient testimony, as the billing records did not contain adequate details regarding the specific tasks performed. Rather the records contained entries such as “answer brief” which the appellate court found to be insufficient. The appellate court noted that neither the fee expert or counsel addressed how the prior research and briefing in the parallel litigation informed the work in the instant matter. The appellate court noted this was significant in that a court's attorney's fees award must exclude excessive, redundant, or otherwise unnecessary hours, citing Florida Patient's Compensation Fund v. Rowe, 472 So. 2d 1145 (Fla. 1985). Based upon the record failing to support the finding of the trial court, the 4th DCA remanded the case to the trial court for a reconsideration and redetermination of reasonable appellate attorney’s fees supported by competent substantial evidence. The 4th DCA reiterated that the fee expert’s focus on the quality of the work and the importance of the work to People’s Trust did not make up for the perceived deficiencies in the position that spending over ninety hours on a single answer brief was reasonable. Whether moving for attorney’s fees or challenging the amount of fees being sought by an opposing party, practitioners should be mindful of the evidence being used to support the claims being made. Parties should pay close attention to whether the hours being sought may be impacted by prior litigation either party may have engaged in. A party must be prepared to address how prior litigation efforts did or did not impact the amount of hours being claimed in current litigation. Lastly, billing records must be sufficiently detailed so as to support any potential future fee claim.

Thought Leadership

First DCA Reverses Excessive Jury Award Unsupported by the Evidence

In December 2019, the plaintiffs filed a claim with Universal for damages caused by a water and sewage back up through the plumbing system and existing through multiple fixtures including the washing machine drain, kitchen sink, dishwasher, bathtub and toilet. Universal investigated the claim, issued payment for resulting water damage totaling $7,000.00 in actual cash value ($12,000.00 in replacement cost value). The plaintiffs sought additional benefits for work needed to access the below-slab cast iron plumbing system due to the failure of the system from rust, deterioration, corrosion and breaks in the line. Universal denied any additional benefits for access. In 2021, the plaintiffs filed suit. During litigation, Universal sent a plumber to inspect the home and the plumber concluded the pipes were clogged but could be cleaned. The plaintiffs’ plumber testified that the plumbing system needed to be replaced due to holes and openings in the pipes. The plaintiffs introduced two estimates prepared by Triad Restoration services totaling $79,680.22 in replacement cost value and $50,219.97 in actual cash value and an executed contract with another company for repairs with the amounts of repair redacted. Since the insurance policy did not provide coverage for repair or replacement of the plumbing system, the jury only had to decide whether the plumbing system needed to be replaced, and if it did, Universal would owe for the access costs; the jury verdict form required the jury to determine both the replacement cost value and actual cash value amounts. The jury asked if it had to rely on the Triad estimates for their amounts. The trial court advised the amount awarded had to be based on the evidence presented at trial and the law given by the trial court. The jury awarded $335,000.00 in replacement cost value or $305,000.00 in actual cash value. Universal motioned for a new trial arguing the amount awarded was unsupported by the evidence and then moved for remittitur. The trial court denied both motions and this appeal followed. The court found that while a jury’s verdict should only be disturbed with caution and discretion, the trial court must give the properly challenged award close scrutiny and determine whether it bears a reasonable relation to the damaged provided, is supported by the evidence, and could have been reached in a logical manner by reasonable means §768.74(3), (5)(d)-(e), Fla. Stat. The court found the trial court did consider the statutory requirements at the hearing on Universal’s remittitur motion and was concerned about a reasonable relation to the amount of damages proved and injury suffered and whether the award was supported by the evidence, but ultimately denied the motion, reasoning that the jury had been properly instructed to fairly and adequately compensate the plaintiffs. The court noted the only evidence providing the basis for the jury verdict was Triad’s estimates and those valued the plaintiffs' claimed loss at $79,680.22 in replacement cost value and $50,219.97 in actual cash value; no valuation evidence reasonably supported the jury verdict. The plaintiffs argued that the jury was entitled to consider more than the estimates, but the court conveyed the evidence provided did not give the jury a way to reach the amounts they awarded. The court was also not swayed by the plaintiffs’ argument regarding inflation and later price increases, but the court noted that no evidence via the contract, nor testimony regarding increase in labor, material, fuel or construction costs were entered into the record.  The court concluded the jury may draw reasonable inferences from the evidence, but it may not supply a damages number by speculation. The court did not find any of the plaintiffs’ remaining argument persuasive either. The court reversed the denial of Universal’s remittitur motion and motion for new trial as to damaged and remanded the case. The court ended its opinion with advising the trial court must determine whether replacement cost value or actual cash value is the property measure of damages under the policy and order remittitur in an amount consistent with that determination and the evidence.