What is Insurance Fraud?

Fraud is deception by false statements or representations with the intent to
obtain financial or other gain. When an insurance company claims that it was
defrauded, it refers to the activity as “insurance fraud.” People use the term
“insurance fraud” when describing defrauding a person or company related to
insurance. However, if criminal charges are brought, then sometimes the charge
may or may not be listed as Insurance Fraud. In federal court, the charges may be a
conspiracy to commit fraud, or another type of fraud charge.

The fraud is usually alleged to be false claims to insurance companies to obtain payments that are not legitimate. Or the fraud alleged could be a false increase in the claim damage to an otherwise legitimate insurance claim.

Federal Prosecutions

Prosecutions in federal court for insurance fraud are usually prosecuted as
Conspiracy to Commit Fraud, Mail Fraud, or Wire Fraud. False claims for health
insurance can be prosecuted as Health Care Fraud or Conspiracy to Commit Health
Care Fraud.

Note that federal criminal laws contain prosecutions for false statements to banks, and bank fraud. These are for federal chartered banks, or banks insured by the Federal Deposit Insurance Corporation.

State Prosecutions

Prosecutions for insurance fraud are common in state court when they involve
claims for homeowner’s insurance or car insurance. This is especially true if the
insurance claim dollar amounts are less then $100,000.00.

In Texas, Insurance Fraud is a specific felony charge with a scale of dollar
amount categories. Here is the Texas charge for Insurance Fraud (in relevant part)
from the Texas Penal Code:

“Title 7, Chapter 35, Sec. 35.02. INSURANCE FRAUD.
(a) A person commits an offense if, with intent to defraud or deceive an insurer, the person, in support of a claim for payment under an insurance policy:
(1) prepares or causes to be prepared a statement that:
(A) the person knows contains false or misleading material information; and
(B) is presented to an insurer; or
(2) presents or causes to be presented to an insurer a statement that the person knows contains false or misleading material information.
(a-1) A person commits an offense if the person, with intent to defraud or deceive an insurer and in support of an application for
an insurance policy:
(1) prepares or causes to be prepared a statement that:
(A) the person knows contains false or misleading material information; and
(B) is presented to an insurer; or
(2) presents or causes to be presented to an insurer a statement that the person knows contains false or misleading material information.

  (b) A person commits an offense if, with intent to defraud or deceive an insurer, the person solicits, offers, pays, or receives a benefit in connection with the furnishing of goods or services for which a claim for payment is submitted under an insurance policy.

(c) An offense under Subsection (a) or (b) is:
(1) a Class C misdemeanor if the value of the claim is less than $100;
(2) a Class B misdemeanor if the value of the claim is $100 or more but less than $750;
(3) a Class A misdemeanor if the value of the claim is $750 or more but less than $2,500;
(4) a state jail felony if the value of the claim is $2,500 or more but less than $30,000;
(5) a felony of the third degree if the value of the claim is $30,000 or more but less than $150,000;
(6) a felony of the second degree if the value of the claim is $150,000 or more but less than $300,000; or
(7) a felony of the first degree if:
(A) the value of the claim is $300,000 or more; or
(B) an act committed in connection with the commission of the offense places a person at risk of death or serious bodily injury.”

Claims

Allegations for fraudulent insurance claims are often those made that increase the damage amount beyond the real damages. Sometimes claims are created when no damage occurred. Fraud can also be based upon false statements to an insurance company when these are additional information to the claim.

Action

In you have been charged, or are under insurance fraud investigation, contact defense attorney John Teakell for help. Mr. Teakell can advise you of the criminal case process, as well as strategize your defense.