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CA Department of Insurance

Insurance Commissioner Jones Announces Arrest of Health Care Provider and Staff for Insurance Fraud

News: 2012 Press Release

For Release: May 4, 2012
Media Calls Only: 916-492-3566
Insurance Commissioner Jones Announces Arrest of Health Care Provider and Staff for Insurance Fraud
Beverly Hills Dentist Faces 113 Felony Counts, Office Manager Faces 10 Felony Counts; Fraudulent Billing In Excess of $339,000

Insurance Commissioner Dave Jones today announced that Tom Kalili, 57, a Beverly Hills dentist and Claudia Ventura, 39, his office manager have been taken into custody on multiple felony counts for insurance fraud, grand theft and tax evasion. Bail has been set at $500,000 for Kalili and $25,000 for Ventura. If convicted, Kalili faces up to 50 years and Ventura faces up to seven years in state prison.

"This health care provider and office manager conspired to defraud insurers," said Commissioner Jones. "My Department is committed to investigating and rooting out those who perpetrate such fraud which eventually costs law-abiding consumers more money via higher premiums."

According to Detectives from the California Department of Insurance (CDI), Kalili, acting as the owner and operator of Beverly Hills Medical Suite (BHMS), directed Ventura to knowingly submit fraudulent billing statements to four separate insurers in the amount of $339,799.99. The investigation revealed that BHMS submitted billing for services not rendered and in most cases the billing involved emergency dental procedures that were never performed. BHMS also submitted false medical reports in support of fraudulent billing, which generally included fictitious mechanisms of injury.

The investigation also revealed that Kalili submitted two fraudulent insurance claims on behalf of himself and his son to two automobile insurers. These claims included medical reports alleging he received treatment in auto accidents in 2005, 2008 and 2009 and his son for treatment received for injuries sustained in a 2009 auto accident. Detectives found that these medical reports were fraudulently prepared. The dentist listed as providing treatment for the injuries claimed by Kalili denied performing the services listed.

On May 3, 2012, a felony arrest warrant was issued by the Los Angeles Superior Court for Kalili on 113 felony counts of Insurance Fraud, in violation of Penal Code Section 550, filing False or Fraudulent Claims; Penal Code Section 549.4, filing False Insurance Claims Pending; Penal Code Section 487.4, Grand Theft; Revenue and Taxation Code Section 19706, filling False Tax Returns/Failure to File Tax Returns 19706; Revenue and Taxation Code Section 19705, Tax Evasion and the following white collar crime enhancements; one count each for violating Penal Code Sections 186.11; 12022.5 (a)(1); 12022.5(a)(2); and 1203.045 (a).

Additionally, a felony arrest warrant was also issued for Ventura on 10 felony counts of Insurance Fraud including violating Penal Code Section 550, filing False or Fraudulent claims; violating Penal Code Section 487, Attempted Grand Theft and violating Penal Code Section 32, Accessory to Insurance Fraud.

This investigation was conducted with the assistance of the California Dental Board and California Franchise Tax Board. The following insurance carriers aided in the investigation: Anthem, United Health Care, Blue Shield, CIGNA, AAA, and Mercury Insurance. This case is being prosecuted by the Los Angeles County District Attorney's Office Workers' Compensation Healthcare and Disability Program.

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The California Department of Insurance, established in 1868, is the largest consumer protection agency in California, regulating the $123 billion insurance marketplace. In 2013 the California Department of Insurance received more than 170,000 calls from consumers and helped recover over $63 million in claims and premiums. Please visit the Department of Insurance web site at www.insurance.ca.gov. Non-media inquiries should be directed to the Consumer Hotline at 800.927.HELP or 213.897.8921. Telecommunications Devices for the Deaf (TDD), please dial 800.482.4833.

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