Insurance Fraud

From the Law Office of Alison Grinter in Dallas, Texas

Contents 1 Degree 2 Statute(s) 3 Caselaw 4 Collateral Consequences 5 Notes

Degree

Filing a claim to an insurer with the intent to deceive it is a Class C misdemeanor if the value of the claim is less than $50; a Class B misdemeanor if the value of the claim is $50 or more but less than $500; a Class A misdemeanor if the value of the claim is $500 or more but less than $1,500; a state jail felony if the value of the claim is $1,500 or more but less than $20,000; a third degree felony if the value of the claim is $20,000 or more but less than $100,000; a second degree felony if the value of the claim is $100,000 or more but less than $200,000; or a first degree felony if the value of the claim is $200,000 or more, or an act committed in connection with the commission of the offense places a person at risk of death or serious bodily injury.  It is a state jail felony to make a false statement to an insurer with the intent to defraud it in support of an application for insurance.

When there are several instances of fraud charged as part of an ongoing scheme or course of conduct, prosecutors can either aggregate  the ammounts (add up the total amount stolen so and use the total to determine the degree of the offense) or enhance the charge to one degree higher than the most serious offense, except that the charge can not be enhanced past a First_degree_felony.

Statute(s)

§ 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 $50;
    (2) a Class B misdemeanor if the value of the claim is $50 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) an act committed in connection with the commission of the offense places a person at risk of death or serious bodily injury.
(d) An offense under Subsection (a-1) is a state jail felony.
(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.
(f) If conduct that constitutes an offense under this section also constitutes an offense under any other law, the actor may be prosecuted under this section, the other law, or both.
(g) For purposes of this section, if the actor proves by a preponderance of the evidence that a portion of the claim for payment under an insurance policy resulted from a valid loss,
injury, expense, or service covered by the policy, the value of the claim is equal to the difference between the total claim amount and the amount of the valid portion of the claim.
(h) If it is shown on the trial of an offense under this section that the actor submitted a bill for goods or services in support of a claim for payment under an insurance policy to the
insurer issuing the policy, a rebuttable presumption exists that the actor caused the claim for payment to be prepared or presented.

Added by Acts 1995, 74th Leg., ch. 621, § 1, eff. Sept. 1, 1995. Amended by Acts 2003, 78th Leg., ch. 605, § 1, eff. Sept. 1, 2003. Amended by: Acts 2005, 79th Leg., Ch. 1162, § 4, eff. September 1, 2005.

Caselaw

Collateral Consequences

Felony Conviction

Insurance Fraud is a Crime of Moral Turpitude

Notes

Restitution in cases like these can be a big deal. This is because the code allows for the court to order the defendant to pay the insurance company's attorney fees, and that can be a pretty sizable sum of money.

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