(As originally published with bells and whistles, Sun, March 27th 2022, 10:27 AM EDT)
WEST PALM BEACH, Fla. (WPEC) – Chemotherapy, radiation, and anti-nausea treatments. They can be painful for cancer patients.
A woman in West Palm Beach apparently went through that but then submitted dozens of claims for payment to American Family Life Assurance Company, and got paid more than $37,000, but authorities say she submitted forged medical treatment and progress notes.
According to the report from the Florida Department of Financial Services, Pilar Garcia was known as Marcela del Pilar Ortiz Leal and in June, 2017, she took out a cancer insurance policy with Aflac.
Then, around October, she was diagnosed with breast cancer and began treatments.
Between January and November, 2018, she filed 13 claims for valid cancer-related treatments.
After that, she went four months without filing any claims.
The report from the state says that from March 2019, through Sept. 2021, Garcia filed 63 claims with Aflac for cancer-related treatments that supposedly happened at two facilities, both located at Good Samaritan Medical Center.
Garcia’s legal trouble began in Dec. 2020. That’s when an Aflac special investigator reported her name appeared on a list of policyholders who were potentially involved in an “Excessive Radiation Treatment” scheme.
That meant her account was flagged for a review of her claims, and the special investigator verified those 63 claims were fraudulent.
On Oct. 27, 2021, the special investigator sent a letter of restitution, asking Garcia to pay back the $37,775 paid to her inappropriately.
On the same day, she referred the case to the state’s Division of Investigative and Forensic Services, Bureau of Insurance Fraud.
A detective from that agency got the case and Aflac’s claim documents less than three months ago, in November.
In his report, he wrote the first bad claim made March 5, 2019,
appeared to have dates that were altered by handwriting an additional ‘1’ in front of the date 1/9/2018 throughout the document to make it 11/9/2018. It should be noted that this investigation determined that Ms. Garcia did have a valid treatment on 1/9/2018 but not on 11/9/2018.
The detective wrote the next three claims were submitted the same month “and had handwritten alterations to the dates.”
He continued, “Pilar Garcia’s next several claims had typed numerals in the dates but appear to have been altered using a copy-and-paste method. One can see the misalignment of dates and times as well as different font sizes.”
Starting with a claim submitted in Aug. 2019, “Ms. Garcia appears to have altered the heading of the treatment notes entirely so that the alterations are not as apparent. However, when comparing Ms. Garcia’s valid records with her forged records, one will notice that the header on the valid records is italicized, while the header on the forged records is not. The remainder of Pilar Garcia’s claims have the non-italicized, typed header.”
In Dec. 2021, the detective used Aflac records to confirm Garcia’s bank account number and found the dates of payment corresponded with the dates of her claims.
In January, he and another detective visited one cancer facility and wrote he “was able to verify Pilar Garcia, aka Marcela Ortiz Leal, did not receive any chemotherapy or anti-nausea treatments” there on Nov. 9, 2018, or after. She’d received treatments before then, but her only office visits after “were for blood work or doctor’s consultations, not for chemotherapy or anti-nausea treatments as stated in Ms. Garcia’s claims.”
Then, the lead detective went to the other facility and verified Garcia “did not receive any radiation treatments at any point on or after Jan. 1, 2019. Ms. Garcia’s last radiation treatment was sometime in 2018. However, Ms. Garcia filed three claims with Aflac for radiation treatments that she claimed happened in 2019 or later.”
Finally, just over a month ago — on Feb. 17, 2022 — two detectives met Garcia at a Dunkin’ Donuts in West Palm Beach. According to paperwork filed, Garcia told them
“she could not remember the exact dates, but she admitted to submitting several claims on her cancer policy. Ms. Garcia then admitted that she had stopped treatments some time ago, but she could not remember the dates. Ms. Garcia began crying and insisting that she was not a bad person. She also expressed some concern about talking to us, and I told her again that the decision whether or not to talk to us was ultimately hers to make. Ms. Garcia explained that she did not want to look bad by not talking to us, but she also did not want to hurt herself by talking to us. After some discussion, she decided to continue talking to us. At that point, Ms. Garcia admitted that although she could not remember the exact dates, the last several claims she submitted to Aflac were false. I then showed Ms. Garcia the altered claim documents, and she admitted she altered them. … She admitted she added the handwritten ‘1’ before the dates…. Ms. Garcia admitted to altering the header as well and agreed that the altered header format was what she used to submit the rest of her fraudulent claims.”
The detective added, she said she changed her name because her ex-husband wanted her to, and he said she “confirmed that the Marcela Ortiz Leal from her claims was in fact herself.”
He found Garcia “engaged in a systematic, ongoing course of conduct with the intent to defraud Aflac over a period of approximately two and a half years.”
She’s charged with fraud-swindle to obtain property between $20,000 and $50,000, and is out of jail on bond.
Garcia has not paid the money back.