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What Qualifies as Insurance Fraud?

In Florida, defrauding, deceiving, or misleading an insurer in an attempt to gain an insurance benefit is a white collar crime that falls under the general category of insurance fraud. Although there are a variety of offenses that qualify as insurance fraud, one of the most commonly charged crimes involves allegations of filing a false insurance claim. However, any action involving insurance claims that is determined by authorities to be deceptive or misleading can result in criminal charges. If you are being investigated for filing a false insurance claim or another insurance fraud offense, it is critical to contact a white collar crime lawyer who can help you begin formulating a strong defense.

Florida Law

Florida law defines insurance fraud extremely broadly, so it is easy for people to get unfairly swept up in investigations and later charged with a white collar crime. For example, even benefiting from a conspiracy to fraudulently obtain benefits is considered insurance fraud. However, in order for this charge to stick, prosecutors must provide evidence that the accused knew that the payments were fraudulently obtained. Furthermore, before a person can be convicted of insurance fraud, prosecutors must also demonstrate that the defendant had the intent to defraud or deceive the insurer and:

  • Presented or prepared a written or oral statement as part of a claim for payment or benefits to an insurer, knowing that the statement contained misleading, false, or incomplete information concerning any material fact;
  • Presented or prepared a false or misleading statement as part of an application for insurance;
  • Concealed important information in an application for insurance; or
  • Submitted a claim for payment under a personal injury protection insurance policy knowing that the payee submitted a fraudulent application when applying for licensure as a health care clinic.

What qualifies as a statement is also interpreted broadly and can include any of the following:

  • Proof of loss forms;
  • Invoices;
  • Damage estimates;
  • Bills for services;
  • Diagnoses;
  • Prescriptions;
  • Test results; and
  • Hospital records.

Filing a false claim is a third degree felony, so defendants who are convicted face up to five years in prison and a $5,000 fine. This is in addition to the financial difficulties and damage to their personal or business reputation that they will undoubtedly face. For instance, doctors who are accused of insurance fraud may be required to give up their license to practice for at least five years.

Additional Offenses

Although filing a fraudulent claim is one of the most commonly charged types of insurance fraud, it is by no means the only one. For example, upcoding, which involves a healthcare provider billing a health insurance company for more expensive services than were actually performed is considered a serious form of insurance fraud. Unfortunately, many healthcare professionals are accused of this offense as a result of paperwork errors or an employee’s unlawful conduct.

Call Our Legal Team Today

Please call 305-670-9919 to schedule a free case evaluation with dedicated Miami white collar crime attorneyĀ Jeffrey S. Weiner, P.A. We are eager to assist you with your case.

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