Seattle couple pleads guilty in storm-damage insurance scheme

The owners of a Seattle construction company have pleaded guilty to attempted theft for an insurance-billing scheme based on inflated storm-cleanup bills.

James and Cheryl-Lin Philo pleaded guilty March 25th in King County Superior Court to two counts of second-degree attempted theft. In addition, their company, Philo Construction Co., of Seattle, is guilty of one count of first-degree theft.

An investigation by Insurance Commissioner's Mike Kreidler's anti-fraud unit found dozens of cases of apparent fraudulent billing by the company.

Here's what happened: In December 2006, a major windstorm swept across Washington, knocking down trees and causing substantial damage to a numerous homes. The Philos hired subcontractors to remove many of those trees from customers’ homes.


In March 2007, a former employee contacted our office, saying that Philo was submitting inflated invoices to insurers. Other workers provided information as well.

An investigation by the agency’s Special Investigations Unit, working with more than 15 insurance companies, found that the Philos had been asking their subcontractors for two invoices for each job. The Philos paid the subcontractors the smaller amount, and then submitted the larger invoice to their customers’ insurance companies for reimbursement.

The markup averaged close to 30 percent, plus another 20 percent that insurers allow for profit and overhead. For example, a $2,150 bill from a tree service company was reported to the insurer as a $2,795 job. Once profit, overhead and sales tax were added, the Philos were paid a total of $3,649.

The Philos also created a fictitious company, Pro Line Construction Resources, to act as a subcontractor when they needed to support a particularly high estimate.

The Philos were each assessed a $500 victim penalty assessment. They'll also pay restitution totalling $19,849.15, and $220 in court costs.

Self-Insurance Receives Seal of Approval

For the past several months I have been managing expectations about the content of separate reports on self-insured group health plans being developed by DOL and HHS. Or more to the point, I have preparing people for reports that conclude all sorts of awful things about self-insured plans. Not that I believe such anticipated criticisms are valid, but rather that it was obvious that self-insurance was “set up” to take a hit based on the PPACA legislative language mandating the studies, in particular the HHS study on the large group market. The stated objective of this study was to compare self-insured plans with fully-insured plans, which is fair enough. But Section 1254 instructs the HHS to investigate multiple perceived problems with self-insured plans while not including similar guidance for fully-insured plans, therefore essentially setting up a one-way fishing expedition. And by the way, this section along with the preceding section mandating the DOL report, were inserted at the last minute as part of the reconciliation process almost certainly at the request of the health insurance industry. So the fix was in from the jump. It has also been my view that there is a negative bias toward self-insurance within the regulatory agencies which would taint the review and reporting process. I say this based on fact that some key officials within these department have previously worked for members of Congress and/or think tanks that have been critical of self-insurance. My suspicion of such bias was heightened after a meeting with HHIS-contracted researchers who asked a series of very pointed about self-insurance that seemed to be “planted” by those with an interest in making self-insurance look bad. The researchers took a particular interest in what they termed “sham self-insurance,” translated to mean self-insured health plans utilizing stop-loss insurance with low attachment points. Now this line of questioning was easily dealt with of course, but we did get the impression that this could well be a situation where the agencies were digging for evidence to support pre-determined conclusions. But apparently there was not a thumb on the scale after all based on a review of the final reports that were released this week. So much for my prescient reputation! The main concern about the DOL report was that they would use bad and/or insufficient data to conclude there are solvency problems with self-insured health plans. But the agency acknowledged that they could not reach any policy conclusions due the lack of quality data. The HHS report appeared to be an opportunity for a host of self-insurance criticisms to be validated by the federal government. You know, the regular canards such as self-insured plans are less costly than traditional issuance because they deny lots of claims and offer skimpy benefits. But I am sure to the consternation of our friends at AHIP and others with market share or other motivations, the HHS report effectively refuted all of the common self-insurance criticisms by concluding little or no difference as compared to fully-insured plans. And for the icing on the cake, consider a little nugget tucked into an appendix of the DOL report which noted that from 2009 to 2010 for employers with more than 200 covered lives, the average fully-insured premium increased by $808 compared to an average increase of $248 for self-insured premiums. So instead of getting branded with a regulatory scarlet letter, self-insurance has effectively received a seal of approval. What an interesting turn of events.

Samaritan Ministries ordered to stop offering unauthorized insurance in Washington state

This post has been updated. See below.

Washington state Insurance Commissioner Mike Kreidler on Friday ordered a health-care sharing ministry to stop offering unauthorized insurance in Washington.

Illinois-based Samaritan Ministries International, a nonprofit corporation, maintains that its member “need-sharing” program is not insurance. Under Washington state law, however, the program is considered insurance.

Insurers doing business in Washington must register with the state, submit their policies and rates for review, and meet state financial solvency requirements. Samaritan Ministries hasn’t done any of those things.

Kreidler on Friday issued a cease-and-desist order telling Samaritan to stop engaging in the unauthorized business of insurance in Washington state, which includes organizing the transfer of money between members.

“Our insurance laws exist to protect consumers and make sure that insurers live up to their promises,” said Kreidler. “Members of groups like this don’t have those protections.”

Samaritan Ministries members agree to pay monthly shares of $135 to $320 to other members who have medical costs, plus a $170-a-year administrative fee. A separate program is available to cover auto-accident injuries.

Members submit medical claims, and the group directs members to send their money to members with medical bills. The group says it has a total of 15,500 members in all 50 states, with shares totaling about $3.5 million per month.

The cease and desist order includes Samaritan Ministries International, its Christian Health Care Newsletter and 20 individuals.
Samaritan Ministries has the right to demand a hearing. The order takes effect immediately.

Update (5/31/2011) The order has been rescinded. On May 11, 2011, Washington Gov. Chris Gregoire signed Senate Bill 5122 into law, excluding health sharing ministries such as Samaritan from regulation under the Washington state insurance code.

Shopping for coverage can pay off

Although the couple that writes this blog, Sustainable Personal Finance, is Canadian, their point in this post on insurance agents is well-taken here as well: it never hurts to shop around.

As with all things in life, however, the cheapest coverage is not necessarily what you need. What is included in the coverage? What is excluded? What is the reputation of the insurer with respect to paying or fighting fair claims? What is the deductible? Does the property coverage provide replacement cost or present value? Do attorney's fees reduce the coverage limits? Is the insurer in danger of going out of business?