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The Collaborative Clearinghouse for Lawsuits and Other Claims Against ACE Group Insurance Companies

COMBINED INSURANCE COMPANY OF AMERICA v. THOMAS et al

ATTENTION: It is possible that this information may no longer be current and therefore may be inaccurate. The index contains both open and closed cases and is not a complete list of cases in which an ACE Insurance Group company is involved. This information is provided to give interested persons an idea of the issues disputed in the indexed cases. For a full understanding of a case, one should read the rest of the court file, including the response. For the most up-to-date and complete information on a case, visit www.pacer.gov or contact the clerk of the relevant court.

Case Number: 
3:12-cv-00254 Search Pacer
ACE Group party(s): 
Court Type: 
Federal
US District Court: 
Eastern District of Arkansas
Date Filed: 
Nov 8 2012

"IV. CAUSES OF ACTION
A. FRAUD/DECEIT

27. The allegations in paragraphs 1-26 are incorporated herein by reference pursuant to Fed. R. Civ. P. lO(c).

28. As outlined above, defendants made false representations of material fact, namely their entitlement to benefits under the terms of the Policy.

29. Specifically, defendants submitted falsified billing documentation from St. Bernard's Medical Center in Jonesboro, Arkansas, and Methodist Hospital in Memphis, Tennessee, as well as falsified and forged attending physician's statements, to support their claims for benefits under the terms of the Policy.

30. Defendants submitted the following fraudulent claims for benefits for the specified time periods:"

"31. Defendants knew that their representations of material fact, namely their entitlement to benefits sought in the above claims, were false.

32. Defendants intended to induce plaintiff to rely on their false representations of material fact by paying benefits sought in the above claims and, further, intended to induce plaintiff to refrain from investigating the above claims by falsely portraying its employee defendant David W. Thomas as terminally ill.

33. Plaintiff justifiably relied on defendants' false representations of material fact by paying benefits sought in the above claims and, further, by refraining from investigating the claims and as a direct and proximate result, sustained damages.

B. ACTING IN CONCERT
34. The allegations in paragraphs 1-33 are incorporated herein by reference pursuant to Fed. R. Civ. P. 10(c).

35. As illustrated by their joint and active participation in the acts alleged herein, defendants David Thomas and Debbie Thomas entered into a conscious agreement to pursue a common plan or design to commit the fraud/deceit alleged herein.

36. Both defendants, David Thomas and Debbie Thomas, actively took part in the fraud/deceit alleged herein.

37. Defendants did commit the fraud/deceit alleged herein.

38. Thus, defendants David Thomas and Debbie Thomas are jointly and severally liable for the damages caused by their fraud/deceit.

C. CIVIL CONSPIRACY

39. The allegations in paragraphs 1-38 are incorporated herein by reference pursuant to Fed. R. Civ. P. 10(c).

40. Defendants David W. Thomas and Debbie L. Thomas knowingly entered into an agreement to accomplish a purpose that is unlawful or oppressive or to accomplish, by unlawful or oppressive means, a purpose that is not in itself unlawful or oppressive. Specifically, defendants entered into a conspiracy to commit the fraud/deceit alleged herein.

41. Both defendants David W. Thomas and Debbie L. Thomas committed one or more overt acts in furtherance ofthis conspiracy.

42. In entering into this conspiracy, defendants David W. Thomas and Debbie L. Thomas had the specific intent to harm plaintiff.

43. Defendants did commit the fraud/deceit alleged herein.

44. Thus, defendants David W. Thomas and Debbie L. Thomas are jointly and severally liable for the damages caused by their fraud/deceit.

D. BREACH OF CONTRACT

45. The allegations in paragraphs 1-44 are incorporated herein by reference pursuant to Fed. R. Civ. P. 10(c).

46. The Policy is an insurance contract between plaintiff and defendants.

47. The Policy set the terms by which defendants are entitled to certain monetary benefits from plaintiff for days defendant David W. Thomas was hospitalized as an inpatient, visited an Emergency Room for treatment, recovered from a surgical procedure or recovered at home following a hospital confinement.

48. Pursuant to the terms of the Policy, defendant David Thomas was required to submit written proof of his claims.

49. Plaintiff did what was required of it pursuant to the terms of the Policy.

50. By making claims for benefits to which he was not actually entitled and by submitting invalid and fraudulent documentation in support of those claims, defendant David Thomas did not do what was required of him pursuant to the terms of the Policy which constitutes a breach of contract which directly and proximately resulted in damages to plaintiff.

E. INTENTIONAL INTERFERENCE WITH CONTRACTUAL
RELATIONS

51. The allegations ofparagraphs 1-50 are incorporated herein by reference pursuant to Fed. R. Civ. P. lO(c).

52. The Policy was a valid contract between the plaintiff and defendant David W. Thomas.

53. Defendant Debbie L. Thomas had knowledge of the Policy.

54. By aiding and abetting defendant David W. Thomas's making claims for benefits to which he was not actually entitled, by actively participating in submitting invalid and fraudulent documentation in support of those claims, and by other acts of intentional and improper interference, defendant Debbie L. Thomas induced or caused defendant David W. Thomas to breach the Policy.

55. Defendant Debbie L. Thomas's intentional interference with defendant David W. Thomas's obligations under the policy directly and proximately resulted in damage to plaintiff.

F. FRAUDULENT CONCEALMENT, WAIVER, AND ESTOPPEL

56. The allegations in paragraphs 1-55 are incorporated herein by reference pursuant to Fed. R. Civ. P. lO(c).

57. By submitting falsified and forged supporting documentation, abusing the trust inherent in defendant David W. Thomas' employment and managerial relationship with plaintiff, and submitting false facsimile messages designed to deter inquiry of plaintiff into defendants' claims, defendants committed positive acts of concealment that were distinct from the conduct that forms the basis of plaintiffs claims, namely defendants' false representations as to their entitlement to benefits under the Policy, and that were so secretly planned and executed as to keep plaintiffs causes of action hidden.

58. In the alternative, by submitting falsified and forged supportingdocumentation, abusing the trust inherent in defendant David W. Thomas' employment and managerial relationship with plaintiff, and submitting false personal messages designed to deter inquiry of plaintiff into defendants' claims, defendants' conduct that forms the basis of plaintiffs causes of action was perpetrated in such a way that the basis of plaintiffs claims concealed itself.

59. Plaintiff exercised reasonable diligence to discover the facts of its causes of action.

60. The point at which plaintiff knew or had reason to know of the basis for its causes of action occurred within any applicable statute of limitations.

61. Accordingly, any applicable statute of limitations was tolled and did not begin to run until the point at which plaintiff knew or had reason to know of the basis for its causes of action.

62. In the alternative, defendants have waived and/or are estopped from asserting the statute of limitations as an affirmative defense to plaintiffs causes of action.

63. Plaintiffs causes of action are therefore timely brought, for the purposes of any applicable statute of limitations, as to each fraudulent claim submitted by defendants.""

The provided text is an excerpt from a document filed in this case. For a full understanding of the case, one should read the complete court file, including the response.

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