Covered

The illinois Administrator has filed a complaint alleging that an attorney engaged in insurance fraud.

At all times between 1993 and 2014, Respondent was a sole practitioner. During that time period, Respondent’s law firm did not provide medical insurance coverage to Respondent or any employees working for his firm. Between 1993 and September 2004, Respondent’s wife, Barbara Lewis (“Barbara”), was employed, and her employer provided medical coverage for Barbara and Respondent through its group insurance plan.

 In June 2002, Barbara Lewis filed a petition for dissolution of her marriage to Respondent in the Circuit Court of Cook County. The Clerk of the Court docketed the matter as In re the Marriage of Lewis, No. 2002D09193.

 Later in 2002, Respondent met and began a romantic relationship with Donna Masterson (“Masterson”). In or about April 2003, Masterson moved into Respondent’s residence.

 On August 16, 2004, a judgment for dissolution of marriage was entered in relation to case number 2002D009193. As a result of the dissolution of his marriage to Barbara, Respondent no longer had medical insurance coverage through Barbara’s employer, and he had no other insurance until such time as he obtained health insurance from Illinois Education Association as set forth in paragraph seven, below.

From at least 2002 through 2014, Masterson was employed by Illinois Education Association – NEA (“IEA”) as a UniServ Director.

At all times alleged in this Complaint, IEA had in effect an insurance policy that provided health and dental insurance coverage to its employees and the dependents of its employees at no premium cost to the employee or dependent. Between 2004 and 2014, IEA’s health care insurance was provided through Blue Cross Blue Shield (“BC/BS”) and its dental insurance was provided through Delta Dental. Under the IEA policy, domestic partners were eligible for coverage if they met certain requirements. Three of the requirements of establishing and maintaining domestic partnership coverage under IEA’s health insurance policy were that: 1) the employee and the domestic partner share the same principle residence and intend to do so indefinitely, 2) they have an exclusive mutual commitment similar to marriage, and 3) they are jointly responsible for the other’s welfare and financial obligations.

 On or about September 30, 2004, Masterson applied for domestic partnership major medical and prescription drug insurance coverage on behalf of Respondent.

In September 2004, Masterson and Respondent met the criteria for domestic partnership under the policy, as described in paragraph 7 above. As a result of Masterson’s application for domestic partnership coverage, IEA provided all family coverage benefits to Respondent, including dental, vision and dependent life insurance. Masterson had no other dependents.

In support of the application for domestic partnership insurance coverage, Masterson and Respondent signed and submitted to IEA under penalty of perjury a joint affidavit. Paragraph two of the affidavit stated, inter alia, that Masterson and Respondent had “resided together continuously (at least 6 months) since April 2003 and intend to reside together permanently.” Paragraph five of the affidavit stated “[w]e are in a committed and mutually exclusive relationship, jointly responsible for the other’s welfare and financial obligations.” Paragraph seven of the affidavit stated “we agree to notify the employer in writing if there is any change of circumstances attested to in [the] affidavit within thirty (30) days of such change.”

As a result of Respondent’s action in signing the affidavit referenced in paragraph 10 above, Respondent owed a duty to IEA to notify it in writing within thirty days of any changes in the circumstances which qualified him for the domestic partnership insurance coverage and were attested to by him in the affidavit.

In January 2006, Masterson and Respondent’s domestic partnership ended and Masterson moved out of Respondent’s residence. As of January 2006, Masterson and Respondent no longer met the requirements for domestic partnership coverage in that that they no longer shared a principle residence, no longer had an exclusive mutual commitment, and were no longer jointly responsible for the other’s welfare and finances, as required under the IEA policy.

 At no time did Respondent inform IEA that their domestic partnership had ended. 14. At no time did Masterson inform IEA that their domestic partnership had ended.

 Respondent’s failure to notify IEA of the end of his domestic partnership with Masterson was intended to deceive IEA into continuing to pay for Respondent’s medical, dental, and other insurance coverage.

Between January 2006 and December 2014, IEA was unaware of the change in status of Respondent and Masterson’s relationship. Therefore, IEA continued to cover Respondent for insurance purposes, and new insurance identification cards were mailed to Respondent at Masterson’s address in February 2011 and in December 2013. Between January 2006 and December 2014, Respondent continued to submit claims, personally or through his providers.

Between January 2006 and December 2014, Respondent’s use of IEA’s insurance coverage for his health insurance needs included at submission of at least 150 insurance claims for medical services, pharmacy services, and laboratory services on Respondent’s behalf, which were paid by BC/BS and totaled at least $16,000. Between January 2006 and December 2014, Respondent’s use of IEA’s insurance coverage for his dental insurance needs included at least 23 claims, which were paid by Delta Dental, and totaled at least $3597.40.

Between January 2006 and December 2014, Respondent had no other medical or dental insurance coverage.

Respondent’s continued use of IEA’s insurance coverage for his health insurance needs between January 2006 and December 2014, during which time he was no longer Masterson’s domestic partner, was dishonest and fraudulent because Respondent was no longer in a domestic partnership with Masterson and therefore no longer entitled to IEA’s insurance benefits.

Between January 2006 and December 2014, while Respondent continued to use IEA’s insurance coverage, Respondent knew that his use of IEA’s insurance coverage was dishonest and fraudulent because he knew he was no longer in a domestic partnership with Masterson, and therefore he was no longer entitled to IEA’s insurance benefits.

Between January 2006 and December 2014, IEA incurred for Respondent $112,514.76 more in medical insurance premiums than it would have incurred for a single plan for Masterson. During that same time period, IEA also incurred for Respondent $6,266.56 more in dental insurance premiums than it would have incurred for a single plan for Masterson.

In or about November 2014, IEA discovered that Respondent and Masterson were no longer in a domestic partner relationship. As a result, IEA notified Respondent that his insurance benefits were being terminated and that he could seek COBRA continuation coverage.

In or about January 2015, Respondent elected COBRA coverage at a cost of $838.54 per month.

(Mike Frisch)