.

Defense Digest

Scheme to Defraud Insurance Carriers May Leave 'Runners' Walking Behind Bars

Defense Digest, Vol. 29, No. 2, June 2023

June 1, 2023

Key Points:

  • A recently introduced bill in the New York State Assembly will hold accident scene runners as criminal defendants for unlawful procurement of clients, patients, and customers. 
  • Runners are most common in staged and intentional accidents. 
  • According to the Department of Financial Services, no-fault fraud reports accounted for 93% of all fraud reports received in 2022 and 90% of all health care fraud reports received since 2018.

New York Insurance Law § 5102 and the corresponding no-fault regulations require automobile insurance carriers to provide a statutory mandatory minimum coverage of $50,000 for “first party benefits” for “basic economic loss” due to personal injury arising out of the use or operation of a motor vehicle. No-fault law provides for prompt payment for medical treatment, so claimants do not need to file personal injury lawsuits to be reimbursed. Under no-fault law, patients may assign their right to reimbursement from an insurance carrier to other parties, including health care providers.

Due to the extremely high volume of claims that must be processed within strict timeframes, the no-fault industry is primed for health care provider fraud. Often, health care providers are assisted by “runners,” who procure patients. 

Significantly, a recently introduced Bill in the New York State Assembly will hold accident scene runners as criminal defendants for unlawful procurement of clients, patients, and customers. The proposed Bill includes the addition of three new sections: (1) N.Y. Penal Law §§ 176.85, 176.90, and 176.95, and (2) an amendment of §176.00 to include new subdivisions which define “runner” and “provider.” 

Under the proposed Bill, a “runner” is defined as “a person, not a provider, who with the intent to obtain a material pecuniary benefit, procures or attempts to procure a client, patient or customer at the direction of, request of, in cooperation with, while employed by, or with intent to solicit a fee from, a provider or from any person who creates the impression that he or she or his or her practice can provide legal or health care services.” See N.Y. Assembly Bill 855, 205th N.Y.S. Legislature (2023). The proposed Bill defines “provider” as a “health care professional, an owner, or operator of a health care practice or facility or an attorney.” See N.Y. Assembly Bill 855. This means an individual charged as a runner or provider could face up to a first degree class D felony, as further defined below.

According to the New York State Department of Financial Services (DFS), no-fault fraud reports accounted for 93% of all fraud reports received in 2022 and 90% of all health care fraud reports received since 2018. See DFS, “Investigating and Combating Health Insurance Fraud,” dated 03/15/2023. In 2019, the DFS implemented investigations to uncover information regarding runners’ involvement in staged accidents and doctors engaging in no-fault fraud for rendering unnecessary medical treatment.

The two most common staged accident scenarios are drivers who intentionally hit their automobiles together or the driver of one automobile causes an accident with an unsuspecting driver of another automobile. See DFS, “Investigating and Combating Health Insurance Fraud,” dated 03/15/2020. An additional scenario involves “jump-ins,” which occur when individuals are not involved in the accident but are added to the accident report.
 
Runners are most common in staged and intentional accidents. After an accident occurs, a runners appear in order to tip-off individuals to medical clinics and law firms for a kickback, and they coach accident victims to exacerbate injuries. Runners receive a pecuniary kickback from clinic controllers and doctors when solicited patients undergo medically unnecessary treatments at no-fault clinics. Subsequently, personal injury lawyers file lawsuits. As a result, insurance carriers shell out millions on unnecessary medical expenses, lost wages, and litigation defense costs—all set in motion by runners, whose sole intent is to defraud insurance carriers.

Should this Bill be passed and enacted, a runner or provider could be charged for the unlawful procurement of clients, patients, or customers in the third, second, or first degree. It would depend on the frequency of occurrences and pecuniary benefit received in exchange.

A runner will be charged in the third degree under N.Y. Penal Law § 176.85, a Class A misdemeanor, if he or she knowingly acts as a runner more than once during a year. A provider would be charged under this section if the provider “uses, solicits, directs, hires or employs another” as a runner more than once during a year and offers a material pecuniary benefit. See N.Y. Assembly Bill 855.

A runner will be charged in the second degree under N.Y. Penal Law § 176.90, a Class E felony, if he or she knowingly acted as a runner on five or more occasions within a 12-month period or received a pecuniary benefit in aggregate of $5,000. The same penalty is applicable to the provider who employs the runner.

A runner will be charged in the first degree under N.Y. Penal Law § 176.95, a Class D felony, if he or she knowingly acted as a runner on more than ten occasions in a 12-month period or received an aggregate of $20,000. Similarly, a provider knowingly employs a runner for ten or more occasions over a 12-month period or offers pecuniary benefit of over $20,000, he or she would face a Class D felony. See N.Y. Assembly Bill 855.

It is hoped that the enactment of Assembly Bill 855 will act as a deterrent to stop runners and providers from engaging in insurance fraud schemes. It may also incentivize insurance carriers to conduct and participate in investigations, which resulted in $518 million in savings and $48 million in recovered funds in 2021. See “Investigating and Combating Health Insurance Fraud,” dated 03/15/2023.

by Danielle Corbisiero, Esq.

Defense Digest, Vol. 29, No. 2, June 2023, is prepared by Marshall Dennehey to provide information on recent legal developments of interest to our readers. This publication is not intended to provide legal advice for a specific situation or to create an attorney-client relationship. ATTORNEY ADVERTISING pursuant to New York RPC 7.1. © 2023 Marshall Dennehey. All Rights Reserved. This article may not be reprinted without the express written permission of our firm. For reprints, contact tamontemuro@mdwcg.com.

Firm Highlights

Result

No-Cause Jury Verdict Secured in Wrongful Death Trial

We successfully obtained a no-cause jury verdict in a 13-day wrongful death trial. The decedent, a 59-year-old man, was admitted to the emergency room on February 15, 2019, with complaints of abdominal pain, decreased appetite, and constipation, despite the use of laxatives. The patient did not complain of any nausea, vomiting, or diarrhea. He had a significant medical history including diabetes, hypertension, prior coronary artery stenting, morbid obesity (with past gastric bypass surgery), longstanding ventral hernia, and back pain. A CT scan revealed multiple hernias and a potential closed-loop bowel obstruction, leading to a surgery consultation. Our client, an emergency general surgeon, interpreted that the patient did not have a closed loop or any significant obstruction and recommended non-surgical management. The patient was approved to have clear liquids, and had a vomiting incident shortly after, but our client was not notified. The patient was returned to NPO status, and after improving overnight, he was returned to “clears” and additional medical and renal consults were ordered. Our client did not receive any communications from the residents/nurses of any changes in the patient’s condition. On February 18, 2019, two rapid responses were called due to increased heart rate and vomiting. It is believed that the vomiting resulted in aspiration, causing sepsis, ultimately leading to the patient’s death. During the trial, the plaintiff’s sole medical expert highlighted imaging on the wrong hernia, which called into question all of his opinions in the case. We made key objections related to the expert testimony, limiting what the allegations were, and preventing new allegations from being made. After approximately two and a half hours of deliberating, the jury returned a no-cause verdict. 

Thought Leadership

Employer/Carriers Must Explicitly Invoke Right to Deny Claim Under “Pay and Investigate” Statutory Provision; Employes Must Always Prove Medical Necessity of Treatment

Koren v. City of Kissimmee/PGCS, ___So.3d___(Fla 1st DCA 6/10/26) The majority opinion in Koren holds that the Judge of Compensation Claims (JCC) properly denied psychiatric treatment because the claimant did not challenge on appeal the JCC’s finding that the requested treatment was not medically necessary. However, Judge K. Thomas authored a detailed concurrence agreeing with the result on the ground that the claimant failed to meet his burden of proving medical necessity. In doing so, Judge K. Thomas also emphasized an important principle: employer/carriers must expressly invoke the 120-day pay-and-investigate provision under Florida’s Workers’ Compensation Act if they intend to preserve their right to deny compensability. Merely authorizing evaluations, without explicitly invoking the 120-day rule, may be insufficient to preserve the right to deny compensability of specific injuries. In Koren, the claimant sustained injuries to his upper lip, tooth, right knee, and right foot when a board gave way on a deck he was repairing for the employer/carrier. The accident was accepted as compensable, and multiple specialists were authorized to treat his physical injuries, including an ear, nose, and throat physician, dentist, orthopedist, and plastic surgeon. The claimant later sought psychiatric treatment and attended an independent medical examination (IME) with a psychiatrist. The IME diagnosed adjustment disorder with mixed anxiety and depressed mood, opining that the condition was caused by “the actual appearance of the scar” resulting from the industrial accident. The IME recommended continued medication, including an antidepressant, as well as follow-up care with a psychiatrist and psychologist. Critically, however, the IME did not offer an opinion regarding the medical necessity of this treatment. The claimant then filed a petition for benefits attaching the IME report and requesting authorization of psychiatric care. The employer/carrier responded by authorizing a psychiatrist, whom the claimant did, in fact, see. However, the employer/carrier neither denied the claim nor issued written notice invoking the 120-day pay-and-investigate provision. The authorized psychiatrist subsequently opined that the claimant’s psychiatric condition was unrelated to the industrial accident and instead attributable to prior employment as a law enforcement officer and volunteer firefighter. The psychiatrist further concluded that the work accident was not the major contributing cause of the condition. Although the employer/carrier stipulated to the authorization of the psychiatrist, it ultimately denied the claimant’s entitlement to psychiatric treatment. The JCC denied the requested benefit. The majority opinion affirmed on the narrow ground that medical necessity had not been established. Judge K. Thomas’s concurrence, however, expands on the legal framework. Under Florida law, an employer/carrier presented with a claim must “pay, pay and investigate, or deny.” To avail itself of the 120-day pay-and-investigate protection, the employer/carrier must affirmatively and explicitly invoke that option, typically through a written 120-day letter. The statutory investigative period does not arise automatically upon the provision of care. Furthermore, an attempt to characterize authorization as a “one-time evaluation” does not avoid waiver, as even a single evaluation may constitute the provision of a compensable benefit. By authorizing psychiatric care without invoking the 120-day provision, the employer/carrier in Koren effectively accepted compensability of the claimant’s PTSD condition. Nonetheless, it retained the ability to contest entitlement to ongoing treatment. While the employer/carrier failed to demonstrate a break in the causal chain, the claimant still bore the burden of proving that the requested treatment was medically necessary. Because the JCC found that the claimant failed to meet this burden, and the claimant did not challenge that finding either below or on appeal, the denial of psychiatric benefits was ultimately affirmed.

Thought Leadership

Appellate Division Affirmed Workers’ Compensation Order Striking Defenses and Ordering Treatment

Kneezel v. Lambertville House, No. A-2729-24 (June 1, 2026) In Kneezel v. Lambertville House, Lambertville House appealed from a workers’ compensation order to strike its defenses and directing it to authorize knee replacement surgery. By way of background, the petitioner worked as a property manager for Lambertville and injured his back and knee in December 2019. A workers’ compensation claim was filed and the petitioner treated at Rothman Institute. He underwent four injections to his low back and was recommended for surgery. The day before, Lambertville canceled and set up a second opinion exam with Dr. Lawrence Barr. The petitioner filed a motion for medical and temporary benefits (MMT), which was ultimately granted by the workers’ compensation judge. As such, he received authorized treatment for his back. The petitioner was then referred for his left knee pain and treatment was provided by Lambertville. He was recommended for a knee replacement, but the petitioner declined at that time. Approximately two years later, he sought additional treatment, which was denied. After obtaining a report from Dr. Dhimant Balar, the petitioner filed another MMT. In response, Lambertville submitted Dr. Zachwieja’s report and surveillance reports. Dr. Balar opined the left knee injury was related to the work accident, whereas Dr. Zachwieja believed it was due to his advanced degeneration as there was no evidence of acute trauma. A hearing on the MMT began in November 2024, with the petitioner testifying his knee pain never went away and he had a lot of trouble walking, especially for more than five to ten minutes. The surveillance investigators were scheduled to testify after, but had to be rescheduled a couple of times. During a conference in early February 2025, prior to when the investigators were to testify, it was discovered that Lambertville did not provide discovery to the petitioner, including the investigators’ information and surveillance footage. The petitioner moved to strike Lambertville’s defenses and sought an order to authorize the left knee treatment. Petitioner’s counsel pointed to Lambertville’s unreasonable delay in providing the necessary information and Lambertville did not file an opposition. In March 2025, the investigators’ testimonies were set for mid-March. On March 14, 2025, petitioner’s counsel advised she was still waiting for discovery and the judge directed Lambertville’s counsel to provide any missing information by March 17, 2025. Lambertville provided video clips after the petitioner had testified so the judge indicated that if everything was not provided to petitioner’s counsel by the end of March 19, 2025, the judge would sign the order granting the MMT. The next day, the judge entered the order striking Lambertville’s defenses and ordering left knee treatment. Lambertville moved for reconsideration of stay of the order pending appeal. Following oral arguments, the judge denied Lambertville’s motion, citing N.J.A.C. 12:235-3.11 (a)(4)(i) that Lambertville was required to provide surveillance after the petitioner’s testimony and that it had failed to do so even after he testified in November 2024. The judge also noted the investigators’ testimonies were rescheduled multiple times and Lambertville had more than enough time to provide the requested information and failed to do so. The judge also noted Lambertville failed to file a response to the petitioner’s motion to strike. In addition, the judge pointed to the petitioner’s testimony, finding him to be credible and observing him to have to stand and move multiple times during testimony. Lambertville appealed, arguing its due process rights were violated as there was no opportunity to be heard and the order was procedurally and factually defective. However, the Appellate Division disagreed, noting Lambertville had sufficient notice and many opportunities to be heard. It was noted Lambertville’s failure to comply with the judge’s requests led to the order. As for the motion to strike, the Appellate Division indicated Lambertville failed to oppose the motion, which provided the judge with the ability to decide without a hearing for an uncontested motion. Ultimately, the Appellate Division found no abuse of discretion and affirmed the judge’s rulings and order.

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Result

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Ray Freudiger and Michael A. Roberts (both of Cincinnati) successfully obtained summary judgment on behalf of their client in a coverage dispute arising from a May 19, 2022, motor vehicle accident. A permissive driver operated a box truck for an interstate trucking company and caused severe injuries to two tort victims. Prior to the accident, the insured had procured a commercial auto policy for the trucking company with stated limits of $1,000,000. Following the accident, the insurer initiated a declaratory judgment action asserting that only reduced bodily injury limits of $25,000/$50,000 applied and later counterclaimed, alleging it would not have insured the driver had he been properly submitted for approval under the policy. After extensive discovery, briefing, and oral argument, the court rejected the insurer’s attempt to shift responsibility for the $750,000 in coverage it was legally required to provide for permissive drivers under Ohio law, granting summary judgment in favor of the insured and preserving $750,000 in liability exposure.

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Event

Florida Insurance Fraud Education Committee (FIFEC)

Sean and Alex will present, "Life Care Plans: From Low Impact to Policy Limits," focusing on the history and expanding use of life care plans in litigation and their ability to transform low impact injury claims to disproportionate high value claims. By focusing on the limitations of life care planners, Florida's tort-reform on medical damages, and the Daubert standard, extraordinary life care plans with inflated future medical care recommendations can be defended.

Thought Leadership

Mitigating Long-Tail Liability: Delaware Court Reaffirms Five-Year Workers’ Compensation Deadline

Williamson v. Donald F. Deaven, Inc., No. N25A-07-004 FWW, 2026 LX 252526 (Del. Super. Ct. June 2, 2026) Claimant was involved in a compensable industrial work accident on May 12, 1995, for a low back injury.  Following this, he received compensation for temporary total disability benefits from July 1996 to September 1996 and for sustaining a permanent impairment in 1997 and 1998.  For the next 23 years, the claimant continued treatment and paid his own medical bills without submitting them to the employer’s insurer.  In November 2021, the claimant filed a petition seeking payment for medical expenses, including prospective surgery and a resulting period of total disability.  The employer moved to dismiss the petition, arguing it was barred by Delaware’s five-year statute of limitations (19 Del. C. § 2361(b)). Pursuant to 18 Del. C. § 3914, insurers must provide prompt written notice of the applicable statute of limitations to invoke the five-year deadline.  Due to the age of the case, neither party had a comprehensive file of the claim and the Board had archived its file of the matter.  The carrier’s computer system retained only bare information indicating that payments occurred and agreements and receipts were filed with the Board in 1997. While the claimant argued that the employer could not prove it provided the mandatory statutory notice, the Hearing Officer recovered the archived file, which contained two “Receipts for Compensation Paid” signed by the claimant.  The receipts explicitly contained the required five-year limitation language, which the claimant testified to signing at the hearing.  The claimant also attempted to introduce evidence of payments he claimed the employer made, which would have extended the statute of limitations.  As a preliminary matter, the hearing officer excluded the testimony about the payments because the claimant did not produce them to the employer.  The Board found in favor of the employer and dismissed the claimant’s petition as time-barred. The claimant appealed the Board’s decision, arguing that he never received adequate notice of the statute of limitations and that the hearing officer’s evidentiary ruling was an abuse of discretion. The Court held that the archived, signed receipts constituted substantial evidence that the insurer fulfilled its statutory notice requirements.  Therefore,  the claimant’s petition was time-barred under the statute of limitations provisions of 19 Del. C. § 2361(b).  Furthermore, the Court reinforced strict procedural compliance: it rejected the claimant’s attempts to introduce evidence of payment on appeal, ruling the argument was waived for failure to preserve it while the matter was still before the Board. This recent ruling by the Court underscores the importance and necessity of robust data preservation and precise compliance with notice requirements.  For risk managers, employers, and insurers, the decision highlights how tight administrative execution protects against catastrophic long-tail liability.

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