Insurance Fraud

State Law:

(a) A person commits an offense if, with intent to defraud or deceive an insurer, the person causes to be prepared or presents to an insurer in support of a claim for payment under a health or property and casualty insurance policy a statement that the person knows contains false or misleading information concerning a matter that is material to the claim, and the matter affects a person's right to a payment or the amount of payment to which a person is entitled.

(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 health care goods or services for which a claim for payment is submitted under a health or property and casualty insurance policy.

(c) For purposes of Subsection (a), information concerning a matter that is material to a claim for payment under an insurance policy includes information concerning:

(1) whether health care goods or services were provided;
(2) whether health care goods or services were
medically necessary under professionally accepted standards;
(3) the nature of the health care goods or services provided;
(4) the date on which health care goods or services were provided;
(5) the medical record of goods or services provided;
(6) the condition treated or diagnosis made;
(7) the identity and applicable license of the provider or the recipient of health care goods or services;
(8) whether property was damaged or lost in the manner and under the circumstances described in a statement related to a claim for insurance payment; or
(9) whether any other claim for insurance payment has been communicated to any other insurer concerning property damage or loss to the same property.

(d) An offense under this section is:
(1) a Class C misdemeanor if the value of the claim is less than $20;
(2) a Class B misdemeanor if the value of the claim is $20 or more but less than $500;
(3) a Class A misdemeanor if the value of the claim is $500 or more but less than $1,500;
(4) a state jail felony if the value of the claim is $1,500 or more but less than $20,000;
(5) a felony of the third degree if the value of the claim is $20,000 or more but less than $100,000;
(6) a felony of the second degree if the value of the claim is $100,000 or more but less than $200,000; or
(7) a felony of the first degree if:

(A) the value of the claim is $200,000 or more; or
(B) the value of the claim is less than $200,000 and the commission of the offense placed a person at risk of death or serious bodily injury.

(e) The court shall order a defendant convicted of an offense under this section to pay restitution, including court costs and attorney's fees, to an affected insurer.

[ Back to top ]