GEICO v. Patel - RICO Case Decision

24 - 191 GEICO v. P atel In the United Sta tes Co urt o f App eals For the S ec ond Circ uit A ugust T erm, 2024 (Argue d: January 31, 2025 Decided: February 3, 2026) Docket N o. 24-191 G OVERNME NT E MPLOYEES I NSUR ANC E C O M PA N Y, GEICO I NDEMNITY C OMP ANY, GEICO G EN ERAL I N SURAN CE C O M PA N Y, GEICO C ASUALTY C OMP ANY, P laintiff s - Appellees, – v. – B HARGA V P AT E L, MD, P A TEL M EDI CAL C AR E, P.C., Defendants – Appellants, J OHN D OE D EFEN DANTS 1 THROUGH 10, Defendants. B e f o r e: C ARNEY, P ARK, an d N ARDIN I, C ircu it Judg es.

2 In this suit brough t under the Ra cketeerin g Influe nced and Corrup t Organizati on Act (“RI CO”), Plaintiff s the Go ver nment Emplo yee s Insurance C ompany (“GEICO ”) and three of its subsidiaries allege that Defendants Dr. Bhargav Patel (“Dr. Patel”) and associat e d entit ies (collective ly, “Defendants”) participat ed in a scheme to defr aud GEICO b y exploiting New York’s no - f ault automo bile insurance laws. Proceeding in t he United States Dis trict Court fo r the Eastern Distric t of New York (Matsumot o, Judge), GEICO fi l ed a com plaint seekin g (1) a ju dgment in the a mount of GE ICO’s paymen ts to Defe ndants on f raudulent cl aims, an d (2) a declarati on that it need not pay an y of Defendants’ pending but a s - yet unpai d claims fo r re imbursement. Defendants then filed ov er 600 independent collection actions against GEICO in various New York sta te courts a nd arbitrati on tribu nals, se eking judgmen ts against GEICO totaling o ver $2 million based on benefits claims Defenda nts had submitted t o GEICO and which GEICO had dispute d or denied. In response, GEICO sough t an order from the district c ourt stayin g all of Def endants’ p ending sta te collection s suits and enjoi ning Defe ndants from fil ing any new collection suits agai nst it unti l the court rul ed on GEIC O ’s pending RICO claims. The district cour t granted the preliminary injunct ion, concluding that GEICO sufficient ly demonstrat ed irreparable har m, serious questions going to the mer its, and a balance of hardships tipping decidedly in its favo r. See Gov’t Emps. Ins. Co. v. Patel, No. 23- CV -2835, 2024 WL 84139 (E.D.N.Y. Jan. 8, 2024). The distri ct court furth er determin ed that, un der the ”in aid of jurisdiction” exception t o the Anti -Injunction Act, 28 U.S.C. § 2283, i t had au thority to tem porarily en join the parallel state c ourt and arbit ration proc eedings. Id. at *11– 13. Defendants tim ely appealed. Reviewi ng the distri ct court’s grant of a p relimin ary injunction fo r abuse o f discretion, we identify no ne. The court did not clearly err in conclud ing that t he parallel proceedings posed a r isk of irre parable harm to GEICO: the potentia l of inc onsisten t judgments posed that r isk, as did the possibility that the alleged overar ching fraudulent scheme woul d be obs cur ed by a r equir ement that GEICO ’s fraud defense be asser ted piecemeal in the numero us individual state collectio n proceedings. Finally, in accor dance wit h our rece nt deci sion in State Farm Mut ual Automo bile Insuran ce Compan y v. Tri- Borough NY Med ical Practi ce, P.C., 120 F.4th 59 (2d Cir. 2024), we conclude that the preliminary injunction did not vio late the Anti - Injunct ion Act. Judge P AR K concur s in the judgm ent in a separate o pinion. AFFIRMED.

3 S TEFAN B ELINFAN TI (Ga ry T sir elman, on the brief), Gary T sirelman, P.C., Brooklyn, NY, for Defendants - Appellants. B ARRY I. L EVY (Henry Mascia, Cheryl F. Korman, Michael A. Sirignano, on the brief), Rivkin Radler LLP, Uniondale, NY, for Pla intiffs - Appellees. C ARNEY, Circ uit Ju dge: In this suit brough t under the Ra cketeerin g Influe nced and Corrup t Organizati on Act (“RI CO”), Plaintiff Gove rnment Employ ees Insurance C ompany (“GEI CO”) and three of its subsidiaries allege that Defendants Dr. Bhargav Patel (“Dr. Patel”) and associat ed en t ities (coll ectively, “Defendant s”) 1 participated in a scheme to exploit New York’s n o - fault automo bile insurance laws with t he aim of defrauding GEICO and other New Yo rk a uto insur ers. GEICO claims that Defendant s submitted to it millio ns of dollars in reimbursem ent claims for “medically unnecessary, ex perimental, excessive, illusory, and otherwise u nreimbursable” treatment expenses — for tre atments b oth provided and nev er provided — related t o injuries suf fered by insured individuals in motor vehicle accidents in New Yor k. App’x at 11 (Compl. ¶ 1). GEICO seeks a judgm ent agains t Defendants in the amou nt of GEICO’s pa yments on f raudulent c laims and a d eclaration th at it need not pay any of D efendants’ p ending r eimbur sement claims. GEICO also soug ht interim re lief, as described below. 1 The Complaint names the following entities as Defendants: Dr. Patel; Patel Medical Care, P.C., Dr. Patel’s related p rofessional corporatio n; an d 10 “Joh n Doe” defendants. Dr. Patel provides medical services through Patel Medical Care, P.C., whic h h e owns, at four clinics located in t he borough of Queens. Unless otherwise indi cated, our reference to “De f endants” does not include the John Doe defenda nts, who are not appella nts here.

4 GEICO f iled this case in the Un ited States District Cour t for the Ea stern Di strict of New York (Matsum ot o, Judge). In r espo nse, the Defendants filed over 600 collection action s against G EICO in variou s New York s tate courts an d arbitrat ion tribun als, seekin g judgmen ts totalin g more than $2 million based on benefits claims they submitted to GEI CO, which GEICO eit her disputed or denied. GEICO t hen sought a preliminary injunction from the d istrict cou rt staying al l of Defen dants’ col lections proceedings and en joining D efendants from filing a ny new col lection action s against it until the district cour t ruled on the pending R ICO claims. The d istrict cou rt granted the preliminary injunction, conc luding that G EICO suf ficiently dem onstrated s erious ques tions going to the merits, irreparable har m, and a balance of hardships ti pping decidedly in its favor. See Gov’t Emps. Ins. Co. v. Patel, No. 23- CV -2835, 2024 WL 84139 (E.D.N.Y. Jan. 8, 2024). The district court’s ir reparable har m find ing rested on G EICO’s show ing of the ri sk of inc onsisten t state court j udgments against it and the lik elihood of unnecessary a nd “potentially unrecoverable” expenditures o f time and resources in the multiple state court proc eedings. Id. at *6–8. The d istrict cou rt further dete rmined tha t, under the “in aid of jurisdiction” exception to the Anti -Injunction Act, 28 U.S.C. § 2283, it had authority to enjoin the parallel state court an d arbitrati on proceed ings. Id. at *11–13. Defendants t imely appeale d. Revi ewing t he dist rict co urt ’s preliminary injunction order for abuse of discretion, we identify no ne. The court did not clearly err in conclud ing that t he parallel proceedings posed a r isk of irre parable harm to GEICO: the possibility of incons istent judgm ents pose d that risk, as did the possibility that Defendan ts’ alleg edly fraud ulent scheme woul d be obs cur ed if GEICO had to assert i ts defe nse piecemea l in the more than 600 individual sta te collectio n proceedings. Finally, in a ccord ance wit h our recent decision in State Fa rm Mutual Aut omobile I nsurance Comp any v. Tri - Boroug h NY Me dic al

5 Practice, P.C., 120 F.4th 59 (2d Cir. 2024) (“ State Farm ”), we c onclude that th e stay orde r and tem porary inj unction did n ot violate the Anti - Injunction Act. For the se and the rea sons furthe r set forth b elow, we AFFIRM. BACKGROUND I. New York ’s No - Fault A utomobile Insurance L aw New York S tate ’s no - faul t auto mobile i nsuran ce law and its impleme nting regulati ons create a system enabling insur ed individuals to av oid common - law tort litigatio n and efficiently recover expense s for t heir me dical and othe r co sts resulting from motor v ehicle accidents. Two decad es a go, shortly afte r the law was enacte d, the New York C ourt of App eals explained that the no - fault s ystem “ supplant [s] common - law tort ac tions for m ost victims o f automobile accidents.” Med. Soc’ y of N.Y. v. Serio, 100 N.Y.2d 854, 860 (2003); see also State Farm Mu t. Auto. In s. Co. v. Mall el a, 372 F.3d 500, 502 (2d Cir. 2004) (same). Under t h at system, insured individual s injur ed in a motor vehicle ac cident may claim and collect benefits of up to $50,000 from their insur er s to cover “ [b] asic econom ic loss.” New Y or k Insura nce Law (“ N.Y.S. Ins. Law”) § 5102(a). Benefits avai lable fro m insurer s may include payments for medical and hospital bills, the cost s of phy sical therapy, ambulance expenses, and the purcha se of necessa ry p rost heti cs. Id. As the “no - fault” name implies, t h e insured s are enti tled to such benefits regardless of their own culpability in an accid ent and wi thout having to f ile suit a gainst othe rs involved i n the accident. See generally Aetna H ealth Pl ans v. Hanov er Ins. Co., 36 N.Y.S. 3d 431, 434 (2016). New York law now also permits insured indiv iduals to assig n their claims fo r no - fault benefits t o eligible healt hcare pro vider s in compen sation for healthcare services provided to t hem. N.Y. Comp. Codes R. & Regs. (“N.Y.C.R.R.”) tit. 1 1, § 65-3.11(a). A n assigne e p rov ider may seek payment for serv ices rendered directly fr om an insu rer

6 using standardized claim for ms. Id. To be eligible to receive pa y me nt in this way, a n assigne e prov ider must meet all “applicable New Yo rk S tate or local lice nsing requirement [s].” Id. at § 65-3.16(a)(12). 2 New York’s no - fault reg im e imp oses “str ict, and brief, time per iods for claim proce ssing” on prov iders, insured individuals, and insure rs. Gov’t Emps. Ins. Co. v. Mayzenbe rg, 121 F.4th 404, 409 (2d Cir. 2024). I nsure rs are allo tted 30 days from submissio n to r eview, investig ate, and verify an insured individual’ s claim for bene fits. Id.; s ee N.Y. Ins. Law § 5106(a); 11 N.Y.C.R.R. § 65-3.8. An insurer that has failed eit her to pay or t o deny a claim within the 30- day pe riod is precluded from raising mo st defenses, including fra ud and lack of medical necessity, in a subseq uent action by its insured to collec t on t he claim. Mayzenberg, 121 F.4th at 409 (“[I]f the insurer fails to adhere to this 30 - day deadline, it will be precl uded from raising mo st defenses in any subsequent lawsui t.”) (citing Fair Price Med. Supply Corp. v. Travelers Indem. Co., 10 N.Y.3d 556, 563 (2008)); see N.Y. Ins. Law § 5106(a). Once duly a ssigned an in sured’ s benefit s, a provider that h as not re ceived timely payment may sue t he insurer either in state cou rt or, under streamlined procedur es, in 2 In Gov ernment Emp loyees Insurance Co mpany v. Mayzenb erg, 121 F.4th 404 (2 d Cir. 2024), we certified to the New York Court of Appeals the question whether an insurer could deny payment for no -fault benefits to a hea lthcare provider under § 65-3.16(a)(1 2) if it determines that the provider improperly paid for patient referr als. Id. at 422. The New Yor k Court of Appeals answered that quest ion in the negative. S ee Gov’t Emps. Ins. Co. v. M ayzenberg, --- N.E.3d ---, 2025 WL 3259882, at *3 (N ov. 24, 2025). An insurer, it said, is entitled to deny reimbursement of a provider’ s no - fau lt benefit cla ims “[o]nly a fter a State regulator has deter mined that [the] provider committed professional miscon duct, and it has suspended, annulled, or revoked the[] [provider’s] licen se” as a result. Id. While t hat decision may bear on the merits of this case, i t has no impact on this ap peal. At issue here is the distr ict court’s analysis of t he preliminary injunction factors in staying Defendants’ pending collections actions, not whether GEICO ultimately may de ny Defendants’ claims for reimbursement based on its determination that Defendants engaged in professional misco nduct.

7 an arbitrati on proceed ing. See N.Y. Ins. Law § 5106(b); 11 N.Y.C.R.R. § 65-4.1; see, e.g., Viviane Etienne Med. Care, P.C. v. Country- Wide Ins. C o., 25 N.Y.3d 498 (2015) (state court proceed ing for rec overy of ben efits). To r ecover, the provider need onl y show t hat the “billing forms were m ailed to and re ceived by the relevant insurance car rier,” and t hat it and did not r eceive payment wit hin the 30 - day pe riod. Viviane Etienne Med. Care, P.C., 25 N.Y.3d at 506–07. An insur er tha t pay s a claim for benefits a nd later discov er s fraud by an assi gnee, however, may sue the assignee for da mages. See, e.g., Mayzen berg, 121 F.4th at 412-13. Whe n an insur er ha s received but not yet paid a claim, it may also seek a judicial declaration that it is n ot liable f or t he unpaid claim. See id. Th e no - fault sy stem i s aimed at providing insured individuals effi cient and predic table recove ry for econom ic loss resulting f rom motor v ehicle accidents. See id. at 409; Med. S oc’y of New Y ork, 100 N.Y.2d at 860. The “ ‘ strict, and brief, t ime periods for claim pr ocessing ’” are intende d to “ensure prompt co mpensation for individuals injured in motor v ehicle accidents without regard to fault ” and “ reduce litig ation burde ns on the cou rts.” Mayzenber g, 121 F.4th at 409 (quoting Ma llela, 372 F.3d at 503). The no - fault arbitr ation procedure, in par ticular, is “an expedit ed, simplified affair meant to w ork as qu ickly and eff iciently as possible. ” Allstate Ins. Co. v. Mun, 751 F.3d 94, 99 (2d Cir. 2014). On the other hand, as we have ex plained, the no - faul t syst em’s expedited nature mean s that it cannot read ily acc ommodate “[c]omplex fr aud and RICO claims, maturing y ears after the initial claimants were fully reimbursed.” Id. II. Factual Background 3 From August 2019 to April 2023, Defendants submitted appro ximately $ 3.4 million in no - fault bene fits claims to GEICO. Accordi ng to GEICO, however, these 3 The factual de scri ption provi ded here is drawn from the allegatio ns of GEICO’s complaint, the materials attached to its motion for a stay a nd injunctive relief, and th ose attached to

8 included claims for t reatments that wer e “ medically unnecessary, exper imental, excessive, illusory, and otherwise unreimbursable.” App’ x at 10 –11 (¶ 1). Th ese claim s, GEICO ur ges, wer e the re sult of a n elabor ate fraud ulent sche me designed to maximize Defendan ts’ profits rathe r than provide any benefi t to the patients Defendants purported to have trea ted. GEICO descri bes the pur portedly fraudulent scheme in gr eat detail in it s complaint and motion - re lated papers. It alleg es that Defendant s’ process to generate a fraudulent claim rested on their “ patient ” procur ement pra ctices. 4 Accord ing to GEICO, Dr. Pat el and his assoc iated provide rs made no e ffort to cultivate legitimate relationships with patient s or to develop a real medical pr actice. I nst ead, thir d - par t y “broke r [s]” (these are the “ John Do e ” d efend ants) referr ed injured individuals to one of Defendan ts’ fo ur clini cs and t hen facilitate d Dr. Pat el’s a ccess to th ose individuals. App’x at 24 (¶ 48). In exchange, Defe ndants compensat ed the thir d parties based o n the volume of patients th ey referred, using kickbac k ar range ments that, i n GEICO ’s vie w, violated N ew Y ork law. Upon receiving a referral, Defenda nts would co nduct an initia l consult ation and examin ation of the p atient at one of t he ir clinics, GEICO relates. Th ese cons ultations — which GEICO says rarely lasted l onger than 30 minutes —served as a “gateway” for Defendants’ opposition to those motions. De fen da n ts fault the distr ict court for relying on evidence that would not be admissible at trial on GEICO ’s claims. W e have observed, however, that a motion for preliminary injunction re quest is often decided in a “less formal” procedur al setting than a trial, and th at oth erw is e -inadmissible evidence m ay be considered at that early stage. Mullin s v. City of N ew Y ork, 626 F.3d 47, 51–52 (2d Cir. 2010). We therefore find un pe rsu asi ve Defendants’ many arguments grou n ded in the ir assertion s of inadm issibility. 4 GEICO alleges both that Defendants bille d for se rvices they did not render and that th ey rendered treatme nt that was unnecessary. For simplicity, we refer to individuals f or whom Defendants submitted claims as “patients,” whether or not Defen da n ts actually provided an y treatment to them.

9 treatments that were “m edically unnecessary, excessive, experimen tal, and. . . illusory,” as we recounted abov e. App’x a t 30 (¶ 76). After the con sultation s, virtually a ll of the referred patie nts would be subjec ted to a “ predetermined, fraudulent” treatm ent schedule a nd to th e clinic’ s billing protocol w ithout regard for their actual medical needs. Id. (¶ 7 7). Th e billing protocol used by the cli nics was d esigned to enable Defendants to “ generate and falsely justify t he maximum a mount of fr audulent no - fault billing” for each patient, as GEICO tells it. Id. at 29 (¶ 71). The result was that Defendant s provided medicall y unne cessar y ser vice s, includi ng so me “ex perimental and invest igational” treatmen ts, for which t hey subseque ntly s ubmit ted be nefit claims to insurers. Id. at 19- 20 (¶ 39). In addition, GEICO says, Defendants sou ght payment f or services never provided: t hey submitt ed claim for ms false ly identify ing Dr. Pa tel as the trea ting provider, even though indepe ndent cont ractors — including, at t imes, unlicensed individuals — provided t he services billed for. GEICO claims that Defe ndants also provided claim fo rms bear ing forged pati ent sign atures for s ervices not ren dered at al l. III. Th is A ction On April 17, 2023, GEICO sued Defendants in the Distri ct Court for the Eastern Distri ct of N ew Yo rk, asserting claims u nder RICO and under Ne w York law on theories of common - la w fraud a nd unju st e nrichme nt. GEICO sough t to recover at least the $711,000 that it had paid to Defen dants in benefit s clai ms. It als o sought a judgment declaring that Defendan ts wer e not entitle d to paym ent of $2.2 million in pending and unpaid claims s ubmitted to GEICO since 2019. Meanwhile, fro m April through November 2023, Defend ants fi led a pproximat ely 605 individual actio ns ag ainst GEICO seeking payment on claims GEI CO had disputed or denied fr om 2019 through 2023. These actions, seekin g sums total ing over $2.675

10 million, included appro ximately 600 lawsuits filed in New York s tate court an d two arbitrati on proceed ings w ith the Americ an Arbitrati on Assoc iation. 5 GEICO claims that Defendants, deciding not to counterclaim in GEICO’s feder al action or to file one cons olidated sta te - court coll ection acti on, instead chose to f ile these hundreds o f individual actions to prevent th e district c ourt from f ully adju dicating its claims against them and to obscu re the ir ongoing f raud. GEICO sought injunctive relie f from th e distri ct court. It as ked for a n order temporari ly enjoining Defenda nts from attem pting to collec t any additional compe nsation from GEICO unde r the no - fault syst em and staying all of Defenda nts’ pending state collectio ns actions. De fendants opposed, arg uing that GEICO had failed to demonstr ate irreparable harm, that t he balance of hardships weighed in the ir favor, and that an injun ction was bar red by t he Anti - I njunctio n Act, 28 U.S.C. § 2283. The distri ct court gran ted the motion, stay ed the pending collectio ns proceedings, and enjoin ed Defe ndants fr om filing any additio nal collect ions actions against GEICO until it had issued a decisio n resolving GEI CO’s underlying action. Defe ndants timely appealed. When GEICO a nd Defe ndants filed t heir briefs in this a ction, we ha d previo usly addressed the availabilit y of injunctive re lief and of a relat ed stay of a paralle l no - fault state c ourt proceeding in only one de cision, a non - precedential summar y order. S ee Allstate In s. Co. v. H arvey Fam. Chiropractic, 677 F. App’x 716 (2d C ir. 2017). In Harvey, we 5 The p arties d ispute whethe r any of t he no - fault claims were filed as ar bitrations rather than state- court collections actions. The district court decided to “rel[y] on the [GEICO employee] declaration and ass ume[], without deciding, that there [were] activ e arbitra tion s” that should be stayed. Patel, 2024 WL 84139, at *5 n.1. In light of the evid ence submitted by GEIC O to support its claim, including an employee’s declaration under oath, we find no merit in Defendants’ argument that the d istrict court abused its d iscretion in credit ing GEICO’s characterizatio n over that offered by Defe ndants.

11 affirmed t he district c ourt’s dec ision to den y the requested preliminary injunction, citing an abse nce of record evidence that the plaintiffs could not be fully compensat ed through a late r award of money dam ages. See id. at 718. After Harvey, however, and w hile the appeal in t his case was pend in g, we decided State Far m. There, we affir m ed a dis trict court’s g ra nt of a preliminary injunct ion staying hundreds of paralle l no - fault state - court and arbitration proceedings in a context pr esenting many parallels to GEICO’s case, as we will e xplain. T he part ies have submitted letter briefs add r essing the effect of State Farm on th is appeal. DISCUSSION I. Standard of Review We review both the district co urt ’s grant o f a preliminary injunction and i ts stay of parallel state court p ro ceedings for a buse of discr etion. Citigroup Glob. Mk ts., Inc. v. VCG Special Opportunities Ma ster Fund Ltd., 598 F.3d 30, 34 (2d Cir. 2010). A distric t court “ ‘abuses’ or ‘ exce eds’ the dis cretion acc orded to it when (1) its d ecision rests on an error of law . . . or a clear ly erroneous factual findin g, or (2) its decision — though not necessarily the pro duct of a legal error or a clearly erroneous factual finding — cannot be located within the r ange of permissible decisio ns.” Zervos v. Verizon N.Y., Inc., 252 F.3d 163, 169 (2d Cir. 2001). II. Analysis A. Preliminary Injunction A preliminary injuncti on is an “extr aordinary and drastic remedy ” that “should not be gran ted unles s the movant, by a clear s howing, ca rries the bu rden of persua sion. ” S tate Far m, 120 F.4th at 79 (quoting Moore v. Cons ol. Edi son Co. of N.Y., 409 F.3d 506, 510 (2d Cir. 2005)). To meet t hat bur den, the movant mus t demonstrate “ (1)

12 irreparab le harm; (2) either a li kelihood of success on the merits or both seriou s questions on the merits and a balan ce of hardships decidedly fav oring the mov ing party; and (3) that a preliminary injunction is in t he public interest. ” N. Am. Soccer League, LLC v. U.S. Soccer Fed’ n, Inc., 883 F.3d 32, 37 (2d Cir. 2018). U nder the t wo - part “seriou s questi ons” standard, the “overal l burden is no ligh ter than the on e the [movan t] bears un der the ‘likel ihood of su ccess’ sta ndard,” for th e movant mus t “ demonstrate bo th serious questions on the m erits and a balance of h ardships decidedly favoring the moving p arty.” State Farm, 120 F.4th at 79–80 (alterati ons omi tted) (quoting Citigr oup Glob. Mkts., Inc., 598 F.3d at 35). Our standard ana lysis begins, however, with a focus on a movant’s claim of irreparabl e harm, which, as “ the single mos t important prerequisite fo r the issuance of a preliminary injunctio n, ” must be s atisfied before the remaining requirements need be consider ed. Id. at 80 (quot ing Fai veley Tr ansp. Malmo AB v. Wab tec C orp., 559 F.3d 110, 118 (2d Cir. 2009)). We do so here. 1. Irreparable ha rm To dem onstrate tha t the district court’s failure to provide t he requested relief will cause it i rreparable harm, the movan t must show an “ inju ry that is neither rem ote nor speculative, but actual and imminent and that cannot be remedied by a n award of monetary d amages. ” S t. Joseph’s Hosp. Health C tr. v. Am. Anesthesiology of Syracuse, P.C., 131 F.4th 102, 106 (2d Cir. 2025) (quot ing New York v. U.S. Dep’t of Homeland Sec., 969 F.3d 42, 86 (2d Cir. 2020)). The injur y must als o be a “ continuing ” o ne. Kamerlin g v. Massanar i, 295 F.3d 206, 214 (2d Cir. 2002) (quoting N.Y. Pa thological & X -Ray Labs., I nc. v. INS, 523 F.2d 79, 81 (2d Cir. 1975)). A threat of irrepa rable harm aris es “where, but for the grant of equitab le relief, there is a substantia l chance that upon fina l resolution of the ac tion the parties cann ot be returned t o the posi tions they pre viousl y occupie d.” State Far m, 120 F.4th at 80 (quot ing Brenn tag Int’l Chems., Inc. v. Bank of India, 175 F.3d 245, 249 (2d Cir. 1999)). So to estab lish irre parable harm, the mov ant “mus t show that

13 there is a co ntinuing har m which cannot be adequate ly redressed b y final r elief on the merits and for which mo ney damages cannot pr ovide adequate compensation.” Id. (internal citat ion and quotation m arks omitte d). T he distr ict co urt conclude d that GEIC O ma de thi s showing. It determined that, if Defendants were “p ermitted to pros ecute th e ongoing coll ection p roceedin gs,” GEICO wo uld “face[] i mminent and non - spec ulativ e r isks of i nconsist ent jud gment s and unnecessary, and pot entially unrecover able, expenditures of t ime and resources on arbitrati ons and state laws uits that m ay be resolved b y the insta nt, pend ing declara tory judgm ent action. ” Pate l, 2024 WL 84139, at *8. Moreover, th e court e xplained, per mitting the col l ections actio ns to proceed would “nullify [GEICO ’ s] effor ts to prov e fraud at a syste matic le vel. . . a nd deprive [GEICO ] of an avenue towards complete r elief in any court.” Id. at *7 (qu oting State Farm Mut. Au to. In s. Co. v. Parisien, 352 F.S upp.3d 215, 232 (E.D.N.Y. 2018)) (emphasis in original). Defendants chal lenge this co nclusion, ar guing that ne ither the waste of tim e and resourc es nor the ri sk of incon sistent j udgments — eith er among stat e courts or b etween state c ourts and the feder al distr ict co urt — wou l d irreparabl y har m GEICO. Any expend iture of time a nd resou rces, they s ay, could later be remedied by money damages, and the risk o f inconsistent judgments is “spe culative and non - immine nt.” Appellants’ Br. at 42. They argu e, too, tha t the state courts are “w ell - suite d” to adjudicate GEICO’s fr au d defenses, id. at 34, and so the cited risk tha t Defenda nts could obscure t heir o verar ching fraudule nt scheme t hrough the state cour t actions, as GEICO conten ds, is non existent. We identify no e rror in the d istr ict cour t’ s assessment that GEIC O has mad e a sufficient show ing of irrepara ble harm. A s the d istrict cou rt correctl y reasoned, the pendency of hundreds o f collections actions pose s a cle ar r isk o f “incon sistent arbitrat ion decisions and judicial judgments, ” simpl y by their numeros ity. Patel, 2024

14 WL 84139, at * 7. In addition, if not stayed, th e individualized nature of the casca ding collect ions actions creat e s a risk that Defe ndant s’ overarc hing fraudulent scheme, a s alleged by GEICO, will be unrecognized by a ny individual state cour t or arbitrat or and that the district court will be precluded from pr oviding complet e relief to GEICO if GEICO proves to be so ent itled. To begi n with, e xpedited no - faul t arbitration s, as G EICO descri bes, “ generally contem plate no su bstantive dis covery ” in advance of a n arbitr al hearing, nor do the y typically per mit “any meaningfu l examina tion or cross - e xamination ” dur ing the hearing. Supp l. App’x at 42 (citing 11 N.Y.C.R.R. § 65-4.1). Indeed, in ex pedited arbitrations, claims are often “heard and resolved in minutes.” Id. Even in state c ourt, where GEICO would have a “greate r ability t o conduc t discovery,” the “limite d nature” of each indiv idual case, invo lving only one billed ser vice, would severe ly undermi n e GEICO’ s capacit y to prove comp lex fraud th rough those proceeding s. Id. In ot her words, GEICO plausibly alleges, as did t he plaintiff insurer in S tate Far m, that t he collections actions are fr agmented proceeding s that “involv e single claims for a single date o f ser vice, so that the se fragmen ted proceed ings end u p obscurin g what [GEI CO] contends is an elabo rate and complex fraudul ent sche me. ” 120 F.4th at 80. In State Farm, we explained that the defendants’ myr iad claims for benefits a s assigne e may wel l look differe nt when view ed in the aggre gate than when viewed in hundreds of individual pr oceedings, creating a risk that “ the arbitra tions and state - court proc eedings [would]. . . help to insulate the alleged fraud from detect ion. ” Id. at 81. So too her e. One reviewin g arbitrator or state cou rt judge, based on an isolated factu al record of on e claim f or one patient, m ight con clude tha t a certain treatm ent was medically necessary for that patient. But t he distri ct cour t her e, review ing aggregated claims, would be able to identify patt erns in those cl aims, a nd woul d be bett er positioned to reach a conclusion (if justified) t hat Defen dants i n fact adhered to

15 predeter mined treatment protocols whet her or not necessary in individual cases, as GEICO alleges. The district c ourt would a lso be b etter position ed, by comparing claims submitted by all fo ur of t he clinics, to d iscern whet her Dr. Patel could possibly have provided all t he treatments for which claims wer e submitted in his name and so to conclude that cert ain claims were either for serv ices provided by third part ies or for services not pr ovided at all, as G EICO contends. Such a con clusi on would be “ exceedingly difficult to establish in a proceeding o n a single claim.” Id. at 80-81. W ithout a stay, then, GEICO faces a real ris k that “the glob al and in tertwined na ture of the fra ud” it allege s could be “effectively obscured.” Id. at 80. C ontrary t o Defenda nts’ conten tion, this ri sk is far from “hypothetic al ” or “speculative.” Appellant s’ Br. at 42–43. As we have e xplained, GEICO has made a sufficie nt sho wing, based on the nature of th e state - c ourt and arbi tration proce edings initiated by Defendants, t hat it mig ht be unable to success fully as sert its global fraud defense in th os e proceedin gs. It need d o no more. See State Farm, 120 F.4th at 80–81. Further, the harm alleged is a lso immi nent and continui ng, as the dis trict court cor rectly explained, because “wi tho ut in junctiv e re lief ... Defenda nts may contin ue to comme nce arbitrati ons bef ore the AAA an d state law suits for ou tstanding c laims.” Patel, 2024 WL 84139, at *7; see also State Farm, 120 F.4th at 81 (finding a harm immine nt and cont inuing because, “ [w]ithout th e preliminar y injunction,” d efendants co uld “cont inue bringing new actions to reco ver the remaining unpaid claims for No - Fa ult benefi ts”). Nor are we persuad ed by Defen dants’ ass ertion that any h arm ar i sing to GEICO from the collection s actions would be c ompensable b y money dama ges. It is true, as Defendants argue, that generally “[m]ere litigation ex pense, even substantial and un recoup able cost, does not cons titute irrepa rable i njury.” Renegoti ation Bd. v. Banne rcraf t Cloth ing Co., 415 U.S. 1, 24 (1974). But GEICO’s incurring litigation expense is not the risk we ide ntify; the risk, as we have explained, is that Defendants could

16 exploit t he individualized nature o f the collections actions to o bscure their fraudulent sch eme and preven t the distric t court from p roviding c omplete reli ef to GEIC O. 6 As we con clude d in St ate F arm, moreove r, t his risk is heighte ned by “the potentia l preclus ive effect of the state - c ourt proc eedings an d arbitrati ons.” 120 F.4 th at 81. Absent a stay, it is virt ually certain that so m e, if no t all, of the expedited coll ectio ns actio ns would co ncl ude be fore the action in the dis trict court. Both state - c ourt judgments and arbitral det erminations can have preclusive effect in fede ral courts. Se e id. (citing Whitfield v. City o f New York, 96 F.4th 504, 522 (2d Cir. 2024) and Jacobs on v. Fireman’s Fund Ins. Co., 111 F.3d 261, 267–68 (2d Cir. 1997)). Indeed, “the No - Fault Ac t specifically prov ides that ‘[a]n award by an ar bitrator shall be binding.’” Id. at 82 (quotin g N.Y. Ins. Law § 5106(c)). In light of this r ule, Defenda nts coul d obtain fac tual determi nations u nfavorable to GEICO in individualized collections proceedings with a limited record and t hen use the preclusive effec t of those determi nations a ga inst GEICO in o ther pr oceedings, both in state and federal cour t. This r eality could bar GEICO from subse quently recove ring on certain claims in its federal cou rt action, even if it were to prevail in that ac tion. In addition to o bscuri ng the exten t of Defe ndants’ allegedly fr audulent scheme, then, the colle ctions ac tions might also prevent th e district court from providing co mplete relief to GEICO if so entitled. See Patel, 2024 WL 84139, at * 7 (highlighting the risk that the 6 What’s more, we have foun d that monetary loss accompanied by other intangible harms may constitute irreparable harm. See, e.g., Register.c om, Inc. v. V erio, Inc., 356 F.3 d 393, 404 (2d Cir. 2004) (holding that monetary damages combined with loss of reputation, good will, and business oppor tuniti es am oun ted to irrepar able harm); Ticor T itle Ins. Co. v. Cohen, 173 F.3d 63, 69 (2d Cir. 1999) (same for monetary damages combined with loss of relationship with client). Accordingly, that one of the harms G EICO may suffer absent a stay is monetary in nature does not undermine the di strict court’s ruling t hat GEICO has shown a risk of i rreparable harm.

17 collect ions a ctio ns coul d “ depriv e GEICO of an avenue to wards complete re lief in any court ”) (emphasis in orig inal and alteratio ns adopted). Defendants as sert that th e district c ourt sugges ted that it “is not boun d by the state c ourt judgmen ts,” and argue on this ba sis that the potential pr eclusi ve effects of the collections actio ns are minimal. Appellant ’s Reply Br. at 5 (emphasis remo ved). But we do not read th e court t o hav e sugg est ed that it wou ld decli ne to credit the outcome s rendered in sta te court p roceedings; rat her, w e read it to have suggest ed that the stay would avoid the po ssibility of contradict ory conclusions in the first place, s ince the state - c ourt and arbitr ation procee dings mig ht be come unn ecessa ry i f GEI CO’ s claims were r esolved in the federal action. Indeed, we re ad the district court’ s decision as expr essly invoking preclus io n conce rns as o ne of th e bases fo r the stay that it entered. See Patel, 2024 WL 84139, at *7 (reasoning that parallel state c ourt proc eedings cou ld “sub ject GEICO to in dependent a nd contradi ctory conclu sions th at ultimatel y may be rendered ineffective by this Cou r t”) (inte rnal cita tion and qu otation marks omitted). 7 In any ev ent, feder al law mandates that federal court s “give to a state- court judgment t he same pr eclusive effect a s would be giv en tha t judgme nt under the law o f the St ate in which the judg ment was rende red.” Whitfield, 96 F.4th at 522 (quoti ng Migr a v. Warren City Sch. Dist. Bd. of Educ., 465 U.S. 75, 81 (1984)); see 28 U.S.C. § 1738. And, as Defe ndants poi nt out, “[c]ollateral esto ppel is so [e] ngra ined in [the] New Y ork judicial system that even a pri or no - fault arbitration award on a decided iss ue will have colla teral estoppel effec t on subse quent court acti ons betwe en the same pa rties.” 7 We also reject any s uggestion by Defendants t hat the district court’s deci sion creates federalism concerns. The collections act ions GEICO seeks to stay were not initiated until after the federal court act ion began. On these facts, it is clear that GEICO did not come to the federal system with the goal of upsetting the now -stayed state co urt proceedings. Cf. Atl. Coas t Line R. Co. v. Bhd. of Loco m otive En g'r s, 398 U.S. 281, 283 (1970).

18 Appellants’ Br. at 33. We have no difficulty in concludi ng, t hen, that the collecti ons proceedings might have preclusive effec t in th e federal action. This possibility, as we explained in State Farm, is enoug h for GEICO to have sufficiently demonstrated a risk of irrepa rable harm to support its claim for relief. S ee 120 F.4th at 81 (“ [I] t is prema ture at this point to a ttempt to ascertain the de finitive preclusive effect o f such proceedings because o ur task at this juncture is solely to determ ine wheth er there i s a suffi cient showing of a risk of ir reparable harm absent an in junction. We believe there is. ”). Defendants, urging a contra ry conclu sion, sugges t that GEIC O had an alte rnative route to a voiding the risks pos ed by the ir numerous collection actions: s eeking consolidation of those ac tions in s tate court. But th e decisi on to consoli date the state court c ollections cases is f or the state cou rts to make. See Berman v. Greenwood Vil l. Cmty. Dev., Inc., 156 A.D.2d 326, 326 (2d Dep’t 1989) (“It is well established that t he power to order cons olidati on rests i n the soun d discretion of the court [.]”). Mo r eover, in view o f the fact - speci fic nat ure of t he claims, case - management challenges, and resource limitations, “consolida tion is highly disfav ored by courts in no - faul t i nsurance case s.” Urban Radiology, P.C. v. GEICO, 28 Misc. 3d 1230(A), at *2 (Kings C nty. 2010); see, e.g., Radiology Res. Network, P.C. v. Fireman's Fund Ins. Co., 12 A.D.3d 185, 186 (1st Dep’t 2004) (den ying cons olidation of 68 no - fault benefi ts claims because “to t ry all 68 claims togethe r would be u nwieldy a nd would c reate a subs tantial risk of confus ing the trier of fact”); Pool e v. Al lst ate In s. C o., 20 A.D.3d 518, 519 (2d Dep’t 2005) (stating th at consolidating 47 no - fault benefit s claims “would pro ve unwieldy and confuse the tr ier of fact”). Gener ally, “ no - fault ben efit clai ms may not be con solidated u nless th e facts and cir cumsta nces ar ise f rom a common accide nt.” Urban Radiol ogy, 28 Misc. 3d 1230(A), at *2. We thus cannot be co nfident that an attempt t o consol idate over 60 0

19 proce eding s would su cceed. We see no need for GEICO to be forced to ven ture do wn this path. 8 Finall y, we r eject, too, Defendants’ argument that the distric t court a bused its discretion in enter ing a stay on the ground that the di strict court c annot off er “full adjudication” of their own claims for reimbursement. Appe llant’s Br. 25 –26. The dist rict court, Defen dants sa y, “igno re[d]” that it would lack jurisdiction over t heir claims and be wi thout power to is sue m onetary judgm ent in their f avor if it de termined they were so entitled. Id. at 26. Defendan ts ignore, how ever, that the district c ourt is likely authorized by 28 U.S.C. § 1367(a) to exercis e supplemental jurisdictio n over their claims, which may be seen as f or ming pa rt of t he same “case o r cont rov ersy” a s GEICO ’s claims. So De fendant s’ ch oice t o file their benefits c laims in s tate court rather than seekin g to assert th em as cou nterclaim s in this ac tion needles sly generates th e logisti cal difficulty they complain of. Moreover, i f Defend ants’ cla ims against GE ICO have merit, they wi ll ultima tely be able to re cover ful ly notwith standing th e stay. Thu s, entering a stay wou ld mean a t worst that an y financial reco very to which Def endants are e ntitled may be delayed, not def eated. 9 8 Defendants also advan ce a related claim: conso lidation is unnecessary for an insurer to obtain broad discovery, th ey arg u e, since New Yor k courts may permit e xtensive discovery in fraud cases. Appellant’s Br. at 40. Th is argument suffer s from the same flaw: de cisions regarding the scope of discovery are discretionary in New York courts. See Lexington Acupuncture, P.C. v. Gen. Assur. Co., 35 Misc. 3d 42, 43–44 (2d Dep’t 2012) (noting di scretionary nature of decision). GEICO need not rely on discretionary rulings to mitigate the serious risks posed by the collect ions actio ns. 9 Defendants also over l ook the cle ar ri sk of harm to GEICO if GEICO were to succeed in proving in district co urt that Defendants are in f act ineligible to receive pa yme n t on th ei r claims. As GEICO points out, the monetary reli ef it seeks in the district court is for paymen ts it has alre ad y made on Defendan ts’ claims; it does not include payments on the claims underlying the pe nding col lections actions. If forced to mak e payments on t hose still- pending claims while the federal action is ong oin g, GEICO risks an i n ability (should it prevail) to recover those

20 We decide, then, that GEICO “s ufficien tly alleges th at the mass ive fraudu lent scheme here bec omes apparent only when the claims are analyzed altogether.” State Farm, 120 F.4th at 80. The risk s created by disagg regating the scheme into individual action s — both financia l and of co ncealment — amount to a llowing ir reparab le harm to GEICO if the actio ns are permitt ed to proceed. We therefore discern no e rror of fac t or of law in the di strict cour t’s co nclusio n that GEICO satisfied the irreparable harm requirement. 2. “Serious question s going t o the merits” In arguin g that GEIC O did not meet the s erious - quest ions st andar d, Defe ndant s’ sole c ontention is that GEICO failed to suffici ently support it s factual allegat ions regarding their fra udulent scheme. S ince De fendant s point to nothin g in the dis trict court re cord dem onstratin g that they advanced any c hallenge to th e adequ acy of GEICO’s complaint and ex hibits in suppo rt of its motion for a preliminary injunction, they have forfeited thi s argument. See Kate l Ltd. Li ab. Co. v. AT&T Corp., 607 F.3d 60, 68 (2d Cir. 2010) (“An arg ument raised for t he first time on appe al is typically forfeited.”). Even if the argumen t were not forf eited, i t has no m erit. The seri ous - quest ions standard is designed to provide “flexibility in the face of varying factual scenarios and the grea ter uncertain ties in herent at the ou tset of pa rticularly c omplex li tigation.” Citigroup Glob. Mkts., Inc., 598 F.3d at 35. For thi s reason, “cou rts applyin g the ‘serious ques tions’ stan dard have the d iscretion t o rely on the pleadings and accom panying affidavits . . . to r esolve preliminary injunction motions.” St ate Farm, 120 F.4th at 83. The district court did not er r in concluding that GEIC O’s alleg ations and evidentiary submissions satisfied t his flexible standard. additional payment s. Th us, as GEICO persuasively d escribes, it could “be left wit h a hollow declaratory judgment” from the district court a fter all the pend ing collectio n s actions have concluded. Appellees ’ Br. at 40.

21 Again, our decision in State Farm all but resolves t his question, for the scheme s alleged and evidence pr ovided are substantially identical. As did the pla intiff insurer in State Far m, GEICO sufficiently alleg e s a complex fraud ulent sche me and pr ovide s details and documentar y evidence to suppor t its allegations. GEICO’s complaint describ es wit h speci fici ty the “histo ry and operati on” of Defendant s’ fo ur clini cs. See State F arm, 120 F.4 th at 84. It outlines the “pr edetermined treatment protoco ls utilized at the gatekeeper clinics and unnecessary medi cal care further provided to patients, including the pre cise medical procedures, de vices, and treat ments rendered.” Id. I t explains how Defenda nts worked wi th unauthorize d third parties a nd ent ered int o financial relationships in exchange for patient referr als, all allegedly in violat ion of state l aw. To supp ort its allegati ons and request for inter im relief, GEICO “attached an affidavit and exhibits.. . detailing t he number of pending a rbitrations and state - court proceedings that Defendants had filed.” Id. It identifie s specific billi ng codes used by Defendan ts to artifici ally infl ate the amoun t the y co uld re cove r and prov ides documents demonstrat ing claims submitted under tho se billing codes. It also descr ibe s testim ony given by Dr. Patel in depositio n that rais ed serious questions about the legitim acy of Defendant s’ busine ss operations. On thes e facts, we have no trouble concluding that GEICO sat isfied the “flexible a pproach” of the ser ious - questions standard. Citigroup Glob. Mkts., Inc., 598 F.3d at 37. 3. Balanc e of har dshi ps As we hav e explained, w he n a pr eliminary in junction is sought base d on a “seri ous quest ion [] going to the me rits ” of a ca se (rather tha n likelihood of succ ess on the merits), t he mo va nt must furt her demonstrate that “the ba lance of h ardships tips decidedly in its favor.” S tate Farm, 120 F.4th at 83–84. Th is facto r r equires t he district court to “balanc e the competing claims of injury ” and “ cons ider the eff ect on each party of the gran ting or with holdin g of the reques ted relief.” Yang v. Kosinski, 960 F.3d 119,

22 135 (2d Cir. 2020) (quoti ng Winter v. Nat. Res. Def. Council, Inc., 555 U.S. 7, 24 (2008)). The harm s to be consi dere d are thos e that “(a) occur[] to the parties ’ legal interes ts and (b) canno t be re medied aft er a fi nal adjudicat io n, whethe r by dama ges or a per manent injunct ion. ” State F arm, 120 F.4th at 85. The distric t court determined th at, if the expedited state cou rt collec tions acti ons were to be stayed, Defendants wo uld at the wo rst suffer from delayed recovery of paymen t. Patel, 2024 WL 84139, at *10. But if t he federal c ourt action is meritorious and the sta te court acti ons not staye d, the cour t r eas on ed, GE ICO wo uld suffer t he irrepar able harm described above. Id. (“[I]f GEICO pr evails, money damages will be inade quate to remedy the Plai ntiffs’ ti me and losse s, and beca use of the ris k of incon sistent ou tcomes.”). W eighing thes e relative hard ships, the court conc luded tha t the balance tipped decide dly in GEICO’s fav or. Defe ndants urge th at in this the distric t court erred: G EICO has n ot yet made an y payment for the disputed claims, they point out, whereas they, the medical care providers, hav e already incurred expenses and now sim ply seek “to rec oup [their ] losses.” Appellants’ Br. at 44. We do not find this argument per suasive. While it may be true that Defen dants would fac e some hard ship from the gra nt of a sta y, we have already ex plained that th e only harm they could suffer would be fin ancial: a delay in securing re imb ursement f or the benefi ts to whi ch they asse r t they are entitled. Defendan ts do not ser iousl y claim that t hey would not eventually receive paym ent on their me ritor ious claims. A ny harm Defendants incur, then, co uld “ be remedied by monetary d amages sh ould they later prevail.” State Far m, 120 F.4th at 85. Nor do we agree with Defendants tha t, in weigh ing the comp eting hardships, the district court did not adequately consider “ the dange r [to the Defen dants] of ‘policy exhaus tion, ’” Appellants’ Br. at 4 4 — that is, the possibility t hat Defendants could be harmed if t he coverag e provided by relev ant insurance policies became ex hausted

23 durin g the pendenc y of the sui t. Becau se t he no - fault syste m caps p ayable no- fault benefits at $50,000 per claimant, Defend ants hypothes ize, individual claimants insured by GEIC O could top o ut, prev enting Defendants fr om later collec ting on some subset o f claims after the stay is lifted. As the distri ct court obs erved, how ever, Defendant s make no eff ort to show th at any speci fic po licies a r e at r isk o f exha ustio n or speci fic clai ms at risk of becoming uncol lect a ble. Pate l, 2024 WL 84139, at * 10 (“ Defend ants do not identi fy any clai ms that might a ctually be rendered u ncollec table, or any reas on why [they ] could n ot collect on th eir claim s from other pa yors shoul d a hypotheti cal polic y be exhausted. ”). We th erefore find no merit in their argumen t that th e district c ourt’s analy sis was fl awed. 4. Public interest Finally, t ur n ing to the la st factor, “whether the preliminar y injunction is in t he public interest” i n vi ew of the co nsequence s of granting injunctive relief, State Farm, 120 F.4th at 85, we co nclude that it is. The no - fault insur ance syst em, as we have descr ibed, is designed “to r educe the burde n on the courts and to provid e substa ntial premi um savin gs to New York motorists.” Mun, 751 F.3d at 99. Fraud on the n o- fault syste m “serves to undermine and damage the integri ty of the. . . system, whi ch was crea ted a s a socia l r epar ations sy stem for t he benefit of consumer s.” Id. at 100. Safeguard ing the integri ty of that system b y “detecting and pr eventing insurance fraud” i s there fore strongly in the public inter est. State Far m, 120 F.4th at 85. Insu rers, by virtue of their c entral role in the syste m, are “uni quely positi oned to combat the depletio n of public resources caus ed by fraudulent claims for No - Fault benefits.” Id. According ly, the public interest in detecting and pre venting insurance fraud is unde rmined when insur ers, alleging fraud, must defe nd “t housands o f

24 arbitrati on s and state- court proceeding s for reimbursement of indivi dual claims. . . into which complex fraud and RICO claims canno t be sho ehorne d.” Id. at 85-86 (internal citation and quotation marks omitted and alte rations adopte d). Pres erving GE ICO’s “ability to pro ve its allegations of a co mplex fraudulent scheme invo lving insurance benef its,” wh i ch w ould be signi ficantly im paired absen t a stay of state court proceedings, is thus indisputably in the publi c interest. Id. at 86. Th e methodical fraudu lent scheme alleged he re, if pro ven, would also hav e worked m any ancillary violations of state la w, including the provision of medical treatmen t by unlicensed technicians and the payme nt of kickba cks for refe rrals — all actio ns in confl ict with the public interest. S ee, e.g., N.Y. Educ. Law § 6530(11) (prohibiting unlicensed pe rsons from perfo rming activities req uiring a license), 6530(18) (prohi biting kickb acks for ref errals). Further more, the scheme as alleged by GEICO invo lves d eliber ate ly bogg ing down scarce ju dicia l reso urces i n serv ice of the fraud. P revent ing those h arms, too, is in the pub lic interest. * * * For these reasons, we id entify no error of f act or of law in the dis trict court’s conc lusion tha t GEICO was entitled to a pre limina ry injunc tion staying th e pending state - c ourt and arbi tration c o llections proceeding s brough t by Defend ants. B. The Anti - In junct ion Act F ederal co urts ha ve long been autho rized by statute to “ issue all writs necessa ry or appropriat e in aid of their respectiv e jurisdictions and agre eable to the usag es and principles of law.” 28 U.S.C. § 1651(a). T his, t he Al l Writ s Act, passed in 1789, empowers federal cour t s to enjoin s tate - court proc eedings when doing so is nece ssary “to pre vent third pa rties from thwarting [a] cou rt’s abili ty to reach a nd resolve th e

25 merit s of the fe deral sui t befor e it. ” In re Baldwin -United Corp., 770 F.2d 328, 338–39 (2d Cir. 1985). The b road authorit y conferred by the All Writ s Act is limited, howeve r, by another venerable statute: the Anti - Injunct ion A ct. 28 U.S.C. § 2283. First enacted in 1793, the Anti - I njuncti on A ct re flect s a “ cor e messag e. . . of respect f or state cour ts.” Smith v. Bayer Corp., 564 U.S. 299, 306 (2011). It “broadly commands that those tr ibunals shall remain f ree fro m interference by federal courts.” Id. (inter nal citation and quotation marks om itted). The Anti - Injunct ion A ct thu s proscr ibes f eder al co urt interf e rence with st ate - court proceed ings. Its proscr ipti on is subje ct, howev er, to th ree narrow e xcept ions: wh ere su ch an in junctio n is: (1) “ expr essly authorize d by Act of Congress ”; (2) “ necessary in aid of its jurisdict ion ”; or (3) necessa ry “ to protect or effectuat e its judg ment s.” 28 U.S.C. § 2283. A district cour t’s a pplicat ion of the Ant i - Injuncti on Act presents a question of law that w e review de novo. State Farm, 120 F.4th at 92. The distr ict co urt here concluded that the Anti - Injun ctio n Act ’s “ in - aid - of - jurisdiction ” exception permitted it to enter a stay of the pe nding state court colle ction s action s. Patel, 2024 WL 84139, at *12–13. 10 It reas oned that, in v iew o f the “o ver 600 pendi ng state acti ons, all of which a re connected to the federal ac tion” and might “conf lict with the declarato ry judgment, ” new state cou rt judgmen ts in action s brought by Defen dants could not “ ‘ peace ably co exist ’ ” with the distric t court’s ju dgment. Id. at *13 (quoti ng United States v. Schurkman, 728 F.3d 129, 139 (2d Cir. 2013)). Defendants take issue with the court’s reliance on this excep tion, whose use it characterizes as “very rare ” and available only in “ext raordinary circumstances ” that it 10 Defendants do not conte nd that the Anti - Inju nction A ct applies either to th e p en di ng arbitration proceedi ngs or to any as- yet unfiled state court colle ction cases.

26 claims ar e not pr esent here. Appe llants’ Br. at 4 8–49. GEICO, o n the other hand, contends not only that th e in - aid - of - jurisdiction except ion is satisfied, but a lso that the distri ct court’s ac tion is permissible under the exception f or matters “expressl y authori zed by Act of C ongress,” arguing that RICO “e xpressly authorizes” federal courts to stay certai n state court procee dings, such as tho se at issue h ere. Appellees ’ Br. at 58–59; see 18 U.S.C. § 1964(a) (“ The di stri ct cour ts. . . shall have j urisdiction to prevent a nd restrain violations. . . of t his chapter by issuing appropr iate orders [. ]”). In light o f our decision in S tate Far m, we need not address further the applicability of the Ant i - Injuncti on Act ’s in -aid- of - jurisdi ctio n exception. I n State F arm, we h eld that in a parallel case inv olving “hundr eds of purport edly meritless state - court proceed ings that he lp further a RI CO violati on,” 120 F.4th at 99, a preliminary inju nction of t hose proceedings is au thorized by RIC O and so “ falls within the ‘exp ressly - authoriz ed’ exception ” to the Anti - In junctio n Act, id. at 98. For purp oses of Anti - Injunc tion Act anal ysis, w e perceive no material distinctio n between the facts and claims presented in Sta te Farm a nd those found here, and Defendant s identify none. Accordingly, S tate Far m dictates our respons e to Defend ants’ argu ment. The district court di d not violate the Anti - Inj unction Act by entering the injunctive relief requested by GEICO. CONCLUSION We have considered Defendants ’ remain ing argumen ts and con clude that they are with out merit. Accor dingly, we AFFIRM the o rd er of the distri ct court.

24-1 91 GEICO v. Patel P ARK, Ci rcuit Judge, concurr ing: I agree with the maj ority that this case is control led by Stat e Farm Mutual Auto mobile In surance Co. v. Tri - Borough NY Med ical Practice P.C., 120 F.4 th 59 (2d Cir. 2024). But tha t de cision misinte rpreted the Anti - Injunction Ac t (“AIA”) an d should be applie d narrowly. Fe deral courts “ may no t grant an injunction to stay proceedin gs in a State court except as expressly authorized by Act of Congress.” 28 U.S.C. § 2 283 (e mphasis a dded). Under this narr ow exception, a stat ute may al low a federal cour t to enjoin a st ate - cour t proceeding that “ in and of itself” viola tes the statute. Vendo Co. v. Lektro- Vend Corp., 43 3 U.S. 623, 645 (1977) (Blac kmun, J., concu rring). But State Farm did no t conclu de tha t the st ate - court suits at issue were themsel ves pred icate acts u nder RICO, so the AIA shou ld have b ar red the federal court from enj oining them. See 120 F.4th a t 98 n.14. I A “[F]rom the be ginning we have had in this country two essentia lly separate legal systems ”— state and feder al courts. Atl. Coast Line R. R. Co. v. Bhd. of Locomotive En g ’rs, 398 U.S. 281, 286 (1970). For adjudicating fed eral claims, the “rank and authority of [tho se] courts are equa l.” Kline v. B urke Const r. C o., 260 U.S. 226, 235 (1922). In fact, lower federa l courts d id not hav e general jurisdiction over federal questions unt il 1875. So for much of our country’s h istory, we “ relied on the adeq uacy of the sta te judicial systems to enfor ce feder al rights.” Amalgamated Clothing Workers of Am. v. Richman Bros., 348 U.S. 511, 518 (1955).

2 T he AIA “ is a n ecessary concom itant of [th is ] dual s ystem of federal and state cou rts. ” Chick Kam Choo v. Exxon Corp., 486 U. S. 140, 146 (1988). E nacte d in 1793, it generally pr ohib its federal inju ncti ons of pending state - court cases, inclu ding when state proceedings “interf ere w ith a protected f ederal right.” Atl. Coast Li ne, 398 U.S. at 294. Otherwise, “[l]itigants w ho foresaw the possibility of more favorable treatment in [federal court] wo uld predictably has ten ” to enjoin parallel state p roceedings. Id. at 286. S uch “ intrusion of f ederal authority into the order ly functioning of a state’s judicial proces s, ” Toucey v. N.Y. Life Ins. Co., 314 U.S. 1 18, 135 (1941), wou ld b e inconsistent with the “well - esta b lished rule” that state and federal courts “are of equa l rank,” Kli ne, 260 U.S. at 235. B T he re is an exception to the A IA ’s br oad prohibit ion for injunction s tha t are “expr essly authorize d” by Congress. 28 U.S.C. § 2283. For exa mple, the removal statute pr ovides that after a case is removed, “th e State court shall proceed no further.” Id. § 1446(d). And 42 U.S.C. § 1983 prohib its unlawful offic ial conduct, inc lud ing the use of state - cour t proceedi n gs to enforc e uncon stitu tiona l sta te laws. S ee Mitchum v. Foster, 40 7 U.S. 225, 2 42 (1972). In these instances, the federal statute can “be given its in tended scope only by the sta y of a s tate court proce eding.” Id. at 2 38. T his is a “narrow” exception. Smith v. Bayer Corp., 564 U.S. 299, 306 (2011) (quotation marks o mitted). Over the 230 -year history of the A IA, the Supreme Cou rt has held that on ly eight statutes prov ide an express authorization. Eac h statute prohibited the continuation of state

3 proceedings — either on its face or because the state proceeding itself violated federal law. 1 But there is no expre ss author ization wh en a statute doe s no t explic itl y author ize injunc tions and th e s tate - co urt su it do es not violate that s tatute. That was the Court’s conclusion in Amalg amated Clothing Workers, where a union aske d a federal court to enjoin a state - court labor disp ute because the Taft-Hart ley Act removed state - court jurisd ict ion o ver the dispu te. See 348 U.S. at 513. T he Taft - H arley Act did not expl icitly aut horize an in junc tion and the “emplo yer’s use of the jud icial p rocess of th e Sta te [did] not amount to an unfair labor practice,” so no injunction could be issued. Id. at 516- 17. The union ’s argument that a state - court decision wo uld “ d islo ca te [] the fed eral scheme ” did not c ha nge that r esu lt. Id. at 517. 1 The federal r emoval statutes, the Limitat ion of Liability Act, the Interpleader Act, the Frazier - Lemke Farm - Mortgage Ac t, and the Federal Habeas Corpus Act all explicitly prohibit ed certai n state - court suits fr om proceeding. See Mi tchu m, 407 U.S. at 234 - 35 & nn.12 -1 6. T he Emergency Price Control Act p ermitted “a federal di strict cou rt to enjoin acts th at violated or threaten ed to violate th e Act,” whi ch was “broad e nough to jus tify an inj unction to res train s tate cour t proceedi ngs.” Id. at 235 n.17. “ The very purpose of § 1983 was to interpose the federal courts between the States and t he people. . . to protect th e people from u nconstituti onal action unde r color of sta te law, w hether that ac tion be e xecutive, legi slative, or judicial.” Id. at 24 2 (qu otation marks omitte d). Finall y, the Cl ayto n Act allow ed injun ctio ns of state proceed ings when “ those proceedings are themselves part of a patter n of baseless, repet itive claims that ar e be ing used as an anticompetitive device ” in violation of feder al antitru st law. Vendo, 433 U.S. at 644 (Blackmun, J., concurring) (qu otation marks o mitted).

4 II In State Farm, th is Co urt held that RICO expressly aut horizes an injunction of state proceedings that are “a pattern of b aseless, repetitive clai ms that are being used to f urther a [RICO] v iolation.” 120 F.4th at 97 (c leaned up). Th at holding misinterpreted the AIA and misread Su preme Court precede nt. A Like this case, St ate Farm involved litigatio n arisin g o ut o f New York’s no - fa ult car insurance sy stem. See N.Y. Ins. Law §§ 5101–5109. Under that syste m, insurers must compensate accident victims regardless of fa ult. See Gov't Emps. Ins. Co. v. Mayzenb erg, --- N.E.3d ---, 2025 WL 3259882, at *1 (N.Y. Nov. 24, 2025). Vic tims o ft en assig n their insurance benefits to hea lth - care providers, wh o then submit claim s for reimbursement to the vic tim’s insurer. The insurer can deny a clai m on ly f or narrow reasons, includ ing if the unde rlying services are m ed ically unnecessary. Id. at *5. 2 In State Farm, a gro up of health - care providers filed 480 state - court benefit s sui ts, al legin g that State Farm M utual Au tomobile Insurance Company (“State Farm”) faile d t o pa y the ir c laim s. 120 F.4 th at 74. B ut State Farm alleged that the provi ders were engag ed in a “mass ive fraudulent scheme.” Id. at 80. It sued in federal court 2 Insur ers ca n also deny claims if (1) t he heal th - care prov ider “fails to meet any applicable New Yor k State o r local licensing requir ement” or (2) the provider “effectively ceded contr ol of their professional se rvices corporation t o unlicensed individuals.” Mayze nber g, 2025 WL 3259882, at *2, 6 (cleaned up).

5 and argued that RICO “ex pressly authorized” an in jun ct ion of the state pro ceedings. Even though the s tate s uits were no t themselves RICO violation s, they “help [ed] to perpetuate and monetize a RICO violation.” Id. at 91. 3 E ach ne w laws uit r is ked giv ing the health - ca re providers more funds to attract new p atients, to admin iste r mor e unnecessary care, an d to continue the ir cycle of fraud. State Farm had seve ral options. It cou ld have defended the 480 cases by arguing the medical care was unnecessary under st ate law or raised its R ICO claim as a co unterclaim. See Tafflin v. Le vitt, 493 U.S. 455, 467 (1990) (state courts have concurrent jurisdiction ov er civi l RICO c la ims). It a lso could have pa id t he cla im s and then sought “ damages or asser t [ed] a claim for unjust enrichment.” Mayze nberg, 2025 WL 3259882, at *5. Fina lly, State Farm co uld have reported the medical providers’ fr aud to N ew York Stat e, as state law required. See id. (ci ting N.Y. Ins. Law § 5108(c)). Th is may have resulted in the termin atio n o f the sta te - court s uits because the “no - faul t statute empowers the S tate” to “proh ibit the [fraudulent] prov ider fr om demanding or req uesting payment f or medical services.” Id. (quotation marks o mitted). 3 S ee S tate Farm, 120 F.4th at 98 n.14 (“ State Farm does n ot appear to conten d that the state - court proceedings here are predicate ac ts under 18 U.S.C. § 1961(1), but in stead that they help further th e RICO vio lation, whic h consists of a pattern of racke teering ac tivity under th e mail frau d statute through other fraudul ent activiti es alleged in th e complaint. In other wo rds, the is sue is n ot whether the state - cou rt proceedi ngs are themselves predicate ac ts, but rathe r that they are all egedly desi gned to perpetuate and monetize the RICO sc heme.”).

6 State Far m d id none of the se th ings. Instead, it sought a federa l injunc tion, ar gu ing t hat it would be ineffe ctive to liti gate in state court, w here procedural rules “obscure[d] the fraud.” State Farm, 120 F.4th at 7 4. State Far m claimed it could not prove the fraudulen t scheme in state court beca use Ne w York law made i t dif ficul t to consolidate cases and the fraud wou ld become “ ap parent only when the claim s are analyzed alt ogether.” Id. at 80. 4 4 State F arm and the majori ty adopt that lo gic in concl uding that ins urers wil l suffer “i rreparable h arm” with out an injunction and th us meet the preliminary injunction standard. See State Farm, 120 F.4 t h at 80; ante at 15 (GEICO will suffer ir reparable harm if it is “unable to successf ully assert i ts global fraud defens e” in state - court and a rbitrati on proceedin gs). B ut that reasoning is undermined by the New Y ork Court of Appeals ’s d ecisi on in Mayzenbe rg, which clarified that “an insurer may not deny a provider’s claim for reimbursement based on alle ged professional misconduct. ” 2025 WL 3259882, at *3. “Professional misconduct” includes the con duct that GEICO alleges was the fraudulen t sche me here — i.e., “[p] ra cticing the profe ssion fraud ulentl y,” “[p]ermitting, aiding or abetting an unlicensed person to perform activities r equiring a license,” giving “any fee or other cons ideration to or f rom a third party for t he referral of a patien t,” and “[f]ailing to exercise appro priate supervision over persons who are authorized t o practice only under t he superv ision of the licensee. ” N.Y. Educ. Law § 6530(2), (1 1), (18), (33); see Joint App’x a t 23 - 24 (GEIC O’s fra ud allegations). So a “global fraud defense,” ante at 15, is not available to insurer s, and they suf fer no “ir reparable harm ” if they ca nnot assert that defense under state law.

7 B This Court should h ave conclude d that th e AIA proh ibited the injunc tion that S tate Farm sough t. T he “expressly au thorized” exception to the AIA is inap plic ab le whe n a federal statute d oes not proh ibit a sta te case from procee ding. U nlike a ll of th e stat utes th at the Suprem e Court has held “expressly authorize” an injunct ion, State Farm did not c laim that R ICO pr ohib ite d the s tate - co urt sui ts. See State Farm, 120 F.4th at 98 n.14. Instead, S tate Farm argued that state courts would re ach incorrect dec isions that would “ further [a ] RIC O violation.” Id. at 98. Its arg ument resembled the u nio n ’s in Am algamated Clothi ng Workers. Just as the union cl aimed that state c ourts wou ld reach a decision contrar y to the Taft - Har tley Act, State Fa rm argued that “sta te c ourts are unlikel y to even recognize the alleged massive RI CO schem e ” and thus would reach decisions contrary to RICO. Id. In b oth cas es, the “assumption upon which the argu ment [for an in junction] pr oceeds is that federal rig h ts will not be adequately protect ed in the state courts. ” A malgamate d Clothing Worker s, 348 U.S. at 5 18. But that as sump tion contradicts t he AIA ’s “core message. . . of respect for state courts.” Smith, 564 U.S. at 306. Unless Congress proh ibit s the state proceedin gs from continuing, we must have “confidence in the s tate courts” and the ir decisions. Amalg amated Clothing Workers, 348 U.S. at 518. C State Far m misread V endo Co. v. Lektro - Vend Corp., 433 U.S. 623 (1977), when it held that RICO “express ly authorized” an in jun ctio n.

8 In Vendo, a sta te co urt rule d tha t Lektr o - Vend had violated noncompete agreements. See id. at 6 27 n.2. B ut Lektro - Vend cla imed that the agreements were unreaso nab le restraint s of trade that violated the Clayton Act, so it asked a fede ral court to enjoin the state - court judg ment, argu ing that the Clayton Act “expr essly a uthorized” an injunction. Id. at 627, 630. The controlling decis ion was Just ice Blackmun’s conc urrence, which concluded that the C layton Ac t “express ly authorize[s]” injunctions “ under nar rowly limited cir cumstances.” Id. at 643-44 (Blackmun, J., conc urring). He explained that, “con sistent[] w ith the decis ion in Ca lifornia Motor Transpo rt Co. v. Trucking Unlimited, .. . no injunc tion m ay is s ue aga ins t cu rre ntly pen din g sta te - court proceedin gs unless those pro ceedings are themselves part of a ‘pattern of baseless, repetitiv e c laims’ that are being used as an antico mpe tit ive d ev ice.” Id. at 644 (c itation omitted). J ust ice Blackmun conc luded that the C layton Act did no t authori ze an injunction in Vendo because Vendo was not using “the sta te - c ourt proceeding as an an ticompet itive device in and of itself.” Id. a t 645. California Motor Transport had held that a “pattern of b aseless, repetit ive claims” can constitute a conspiracy to re strain trade under the Clayton Act. 404 U.S. 508, 513 (1972). 5 So by concluding that th e 5 That holdi ng was an exc eption to the ru le that “[t]hose wh o petition governm ent for redres s are general ly immune f rom antitrust l iability.” Pro. Real Est. Invs., Inc. v. Columbia Pictures Indus., Inc., 508 U.S. 49, 5 6 (1993). A “pattern o f baseless, repetitiv e” claims is thus an antitrust - spe cifi c te rm referrin g to “sham ” judicial proceedings that may thems elves violate th e antit rust laws. Id. at 57-59.

9 Clayton Act authoriz e s an injunction only when st ate proceedings are “part of a pattern of baseless, repetit ive c laims, ” Justice Blackmu n was saying that the Clayto n Act auth orize s a n injunction only when a series of st ate proceeding s “in and of itsel f” violates the Clayton Act. Vendo, 433 U.S. at 644-45 (B lackmun, J., co ncurring) (qu otation marks omitted). That ho lding trac ks the Supreme Court’ s precedents that a statute must prohibit the continuation of state proceedi ngs to “expressly author ize” an injunct ion. State Farm misread the words “pattern of baseless, repetitiv e claims.” Over looki ng the spec ial significance of th at phr ase in antitrus t law, State F arm interpret ed Justice Blackmun ’s concu rrence to hold th at the “ex pres sly authorized” exception ap pl ies when “a pattern of baseless, repetitive cl a ims. . . further [s] a violation of a federal statute.” 120 F.4th at 94 (quotation mar ks omitted). So it authorized the injunction of 480 state - c ourt s uits as a “ patte rn of baseless, rep etitive claim s ” furtherin g an allege d RICO viola tio n. Id. at 98. That hold ing departed from the well - es tabl ished rule that a federa l statute mus t pr ohibit th e con tinua tion o f sta te proce edin gs to “expressly author ize” an injunct ion. III Although State Farm controls this case, it should be read narrowly. First, State Farm described itself as “l imited to the unusual circumstances [of] a massive scheme including h undreds of purported ly meritless stat e - co urt proceedin gs that help further a RICO violation.” 120 F.4th at 99; see also id. at 97 (“ [T] he narrow path carved by Vendo applies only in rare circumsta nces. ”). S o it do es not suggest th at any fe deral statute may authorize i njunctions of

10 “baseless, repetitive claims. ” It remains open whether statut e s oth er than RICO authorize injunctions of a “pa ttern of baseless, re petitive claims,” or whether RIC O its elf authorize s an inju nc tion when a pattern of claims doe s not involve h undreds of cases. 6 Second, State Farm d oes “ not que stion or qualif y in any wa y the principles of equ ity, comity, and fe deralism tha t must restr ain a federal court when asked to en join a state cour t procee ding.” Mitchum, 407 U.S. at 243. C ourts should not act in the “absence of the factors nec essary under equitable principles to justif y federal intervention.” Young er v. Harris, 401 U.S. 37, 54 (19 71). T he recent decisi o n of the New York Court of Appea ls i n Mayzenberg makes clear that equ itab le princ iple s mi litate ag ainst state - court injunction s in cases l ike th is one. Mayzenberg e xp lained that the ju dic ial pr oc ess is not insurers’ primary recourse when they receive fra udulent no - fault claims. See 20 25 WL 3259882, at *5. Ne w York ’s le gisla tur e has enacted a “carefully crafted statutory framework” tha t vests auth ority for “ guilt and adequate punis hment for professiona l misconduct,” inc luding fraud, in the State ’s Bo ard of Regents. Id. at *6. It “r equires every insurer to report ” frau dulent conduct to the State a nd empowers th e Sta te to “ proh ibit the pr ovider from dem anding or requesting paymen t for medical servic es. ” Id. a t *5 (quotation marks omitted). The statu te’s purpose is to ensure that 6 Recently, some cou rts have read State Farm as “enabling district courts to enjoin ongoi ng state - cou rt collectio ns proceedings.” Gov’t Emps. Ins. C o. v. Akiva Imaging Inc., No. 1:24 - CV - 6 549, 2025 WL 1434297, at *2 (E.D.N.Y. May 19, 2025). State F arm did not reac h that broad c onclusion.

11 insurers cannot “de lay and deny n o - fault pa yments ” wi thout th e State’s intervention. Id. at *6. Enjoining state proce edings when insu rers — including GEIC O here — have not sought recourse from t he State vi o lates the princi ple s of federalism and comity. See Mi tchum, 407 U.S. at 243. Federal cour ts should “ seek to avoid ne edless conflict wit h state agencies and w ithhold re lief by way of in junct ion where state remedies are availab le and adequate.” Cap. Serv. v. NLRB, 34 7 U.S. 501, 504 (1954). IV I concu r in the judgment because we a re bound by our deci s ion in State Far m. But State Farm ’s ana lysis of the “expr essly authorized” exceptio n to the AIA departed from Supreme Court precedent and should be read n arrowly.