Insurance Benefits Fraud Defence Lawyers. 416-DEFENCE | 1-866-DEFENCE.

Donich law is one of the few Firms to have defeated and concealed insurance fraud investigations which begin with audits to reconcile claims with practitioners or billing providers. Many investigations begin in Ontario where insurance providers are located, but involve employees and law enforcement across the country, including British Columbia, Alberta and Quebec. Early signs of a suspected insurance fraud investigation includes suspending access to claims or benefits coverage. These investigations then proceed with a workplace investigation, employee interrogation and finally to criminal charges. Insurance fraud investigations are complicated and difficult to defend because they require four different legal skills to fully protect the client, including insurance, employment, regulatory and criminal legal experience. They become more challenging to defend if the person is a licensed professional with a regulator, such as an accountant, teacher, nurse, dentist or other healthcare provider because the college will conduct its own independent investigation. We have successfully defeated investigations from as low as $200 in alleged fraud to $60,000.00, with York Region Organized Crime Bureau and Durham Financial and Organized Crime Unit for both employees and billing providers such as dental clinics.

The Criminal Code states that an individual commits fraud when he or she, by deceit, falsehood or other fraudulent means defrauds any individual or the public of any money, property, belonging, service and/or security. The accused must have intended to defraud the individual or public. Fraud happens in a wide variety of contexts and situations and our office has experience handling a variety of fraud related charges, including insurance fraud. Insurance companies are conducting joint internal investigations with the plan member’s employer and providing evidentiary briefs to law enforcement. In many cases, these offences are treated as internal employee thefts, since the fraudulent payment(s) received were funded by the employer. The Firm has been involved in several insurance benefits fraud investigations, which are commonly referred to police by Sun Life, Canada Life and Manulife.

Many employers such as Canadian Banks, Accounting Firms, Teachers’ Unions and Pension Plans, Ontario Teaches Insurance Plan (OTIP), Tech Sector Employers, Hospitals and Health Care Providers, Crown Corporations such as Ontario Power Generation (OPG) and Canada Post, all levels of Municipal, Provincial and the Federal Government(s) are jointly investigating, terminating and reporting employees caught with benefits fraud to law enforcement. We are one of the few businesses which handles multiple aspects of insurance fraud litigation including civil, employment, regulatory and criminal defence. This reduces the need to hire multiple Firms for complex problems.

The Firm regularly defends plan members facing allegations of insurance fraud from Sun Life Financial, Manulife Financial, Green Shield, Desjardins and Great-West Life Insurance among others. Although most insurers are based in Waterloo, Ontario where investigations are conducted and prosecuted, we have helped clients in many parts of the country. These insurance companies have recently developed sophisticated data mining software to apprehend plan members claiming insurance benefits through mobile apps and online claims. The University Health Network recently recovered 2 Million Dollars for Sun Life Insurance from hospital employees fraudulently claiming, massage therapy and chiropractic services among others.

The English Catholic Teachers’ Association and other Teachers’ Federations have been aggressively investigating, terminating and referring insurance fraud allegations to law enforcement throughout Ontario. The evidence is also being referred to the Ontario College of Teachers for widespread prosecution and published online, including the College of Nurses. The Firm has also represented members of the TTC in complex insurance schemes and acted for Doctors and Dentists accused of inflating or misrepresenting claims for services rendered to a number of insurance companies.

The Firm has successfully defended employees facing allegations of insurance fraud at RBC, CIBC, TD, Scotiabank, RBC, KPMG, PWC, EY, City of Toronto, Canada Post, Canada Pension Plan, Canada Revenue Agency, Toronto Fire, Durham Police, Provincial and Federal Government, Cisco, Salesforce, Air Canada, Members of the Toronto and Catholic Teachers’ School Board, Toronto District School Board, Ontario Teachers Insurance Plan (OTIP) members, and many other businesses across Canada. The Firm also works for businesses being investigated for insurance fraud stings, including orthotic schemes where numerous employees of the same organization often attend and are collectively investigated. These are joint investigations between the insurer, employer and law enforcement where information is shared and collaboratively gathered for prosecution.

In September 2022, Jordan Donich defended at $21,000.00 Sun Life benefits fraud investigation with a large Canadian Bank in its Case No. 35****0. The employee had allegedly been making false psychology claims and received cash including under her partners benefits plan with Sun Life. This jeopardized the employment, income and liberty of the entire family unit. Both Sun Life and the bank confirmed reporting to law enforcement in British Columbia. The Firm was able to quickly challenge the credibility of the therapist and provided fresh defence evidence. The matter was then discreetly resolved without a termination or criminal charges.

The Firm defended a husband and wife under investigation for insurance benefits fraud reported by Manulife in Ontario in its Case No. 83****3. The couple resigned from their employment during the investigation hoping to avoid consequences prior to retaining the Firm. Eight months later, they were contacted by the RCMP in Alberta for an arrest for Fraud Over $5000. In a rare occurrence, Jordan Donich was able to halt the arrest before charges were laid. This is typically a risky strategy, as the evidence could have been used against the clients, but was successful at preventing an arrest and the further damage associated with being fingerprinted. The couple did not have to attend the division nor were they ever charged with any offences.

In April 2021, the Firm resolved a $15,000.00 Manulife Fraud with a large U.S. Tech Employer in its Case No. 21****5. The incident was in the process of being referred to law enforcement and involved alleged false massage, psychology, physiotherapy and dental claims. The Firm was able to negotiate a resolution with U.S. Legal Counsel in California over 4 months which avoided any reporting to the police. Ultimately, the customer was able to obtain new employment discreetly and contain any serious career damage.

In June 2021, the Firm resolved a $16,000.00 Sun Life Financial benefits fraud with a Fortune 500 American company with offices in Toronto in its Case No. 42****9. The alleged fraud extended back approximately 5 years with multiple family members. When the fraud exceeds $5000, it almost always involves alleged false claims from multiple people over an extended period of time. Sun Life reported the discovery to the client’s employer. The Firm conducted 6 months of independent investigation and was able to establish problems with the delisted business, ultimately saving the client’s job without any notification to law enforcement.

In February 2021, the Firm defended a Canada Post employee alleged to have defrauded Sun Life $8000.00 in its Case No. 03****2. The matter was referred to Ottawa Police by Sun Life and the accused contacted for investigation. The Firm was able to challenge the alleged false claims and ultimately saved the accused’s employment after negotiations with national legal counsel, including avoiding criminal charges. This was an exceptionally rare outcome as nearly every employee is terminated where some evidence of fraud exists.

In the Firm’s Case No. 42***4, it resolved a dual insurance fraud investigation between husband and wife who were employed at the same Crown corporation in Ottawa. The value of the alleged loss exceeded $5000.00 between the couple. Both were internally investigated in relation to the joint Sun Life and employer probe which extended several years of claims. The investigation was complicated, given the financial stability of the entire family unit was at stake. The Firm was able to save the employment of its client, avoid any reporting to law enforcement, including without paying any restitution.

In October 2020, after nearly 18 months of litigation, the Firm resolved a $34,000.00 Sun Life fraud investigation for a Dental Clinic without criminal charges in its Case No. 84****3. Like many insurance fraud allegations, the matter was reported to police and investigated by financial and organized crime in York Region and referred to the RCDSO. The Firm achieved the result by challenging the admissibility and reliability of the evidence.

In the Firm’s Case No. 20****4 it resolved an $18,000.00 Canada Life Insurance Fraud allegation where the spouse of the customer was allegedly making false claims without the knowledge of the plan holder. This is a surprisingly common occurrence. The matter was referred to OPP Police for investigation. Over a period of 12 months, the Firm was able to tactically navigate the investigation which ultimately led to no criminal charges for the plan holder our his spouse.

In the Firm’s Case No. 20*****6 it resolved two insurance fraud allegations where an accountant was alleged to have defrauded two separate large Bay Street accounting Firms in Toronto, after quitting the first job and migrating to new employment. We were also able to broker a resolution where the employer would not report to law enforcement, ultimately avoiding a criminal investigation.

In many cases, the Firm has negotiated a resolution without the notification of law enforcement, thereby avoiding charges and a criminal record. Insurance companies will often protect their interests, specifically indicating that any re-payment for questionable claims will not limit the insurers right to consider further action, including referral to law enforcement, employers or regulators.

Many people want to instantly pay back money to avoid potential employment, regulatory and criminal consequences. They often feel that because the value may be low, they will not be prosecuted. Unfortunately, the value is not relevant and the cases with the most evidence are likely to be prosecuted more aggressively. Employers will often grant employment amnesty if the employee comes forward and returns the money, however, this does not protect the employee from reporting to law enforcement and/or regulators. This perceived pardon is only for the person’s job which becomes redundant when the are later criminally charged or reported to their regulator. Nurses presently working at UHN and Baycrest Hospital are now being prosecuted 2 years later by the CNO, after they repaid funds to the insurance company.

This is especially complicated if the accused is a professional, such as a Nurse, Massage Therapist, Physiotherapist, Accountant, Chiropractor, Dentist, Optician, Pharmacist, Teacher, Social Worker, Government Employee, Unionized Worker or employed in a respected organization.

The insurance companies often demand payment for large sums of money dating back years. Unfortunately, paying this money back whether or not the allegations may be true does not necessarily stop criminal charges, civil prosecution or employment consequences. The Firm has experience defending allegations of insurance fraud across the entire spectrum, including having clients retain the Firm months after payment is made when law enforcement gets involved.

Legal Information

What is Insurance Fraud?

Insurance fraud refers to any act committed by an individual with the intention of obtaining payment from an insurer through fraudulent means. There is a wide array of acts that may be included in the definition of insurance fraud and the severity of the offence may differ significantly between cases. Acts of insurance fraud can range from an individual slightly exaggerating damages in a claim, to an individual lying or omitting something on an insurance application, to an individual deliberately causing damage in order to collect a pay out from the insurance company. In addition to exaggerating or falsifying an insurance claim, omitting information on a claim will also constitute insurance fraud.

In addition to committing insurance fraud in relation to physical property, personal injury insurance fraud may also be committed and is just as serious as a fraudulent insurance claim referencing physical property. Personal injury fraud refers to fraudulent claims made in regards to physical injuries allegedly suffered by an individual in an accident. Personal injury fraud may include exaggerating or inventing injuries on an insurance claim, making claims for pre-existing conditions or injuries that did not result from the accident that is the subject of the current claim, exaggerating the length of recovery time for an injury, or health care practitioners exaggerating or inventing injuries of patients in order to bill more for medical services than were actually rendered.

Those guilty of committing insurance fraud can range from organized crime groups to everyday citizens to health care providers. Health care providers may commit insurance fraud by billing for services that they did not render. This type of insurance fraud is generally more systematic and often results in a large sums of money being defrauded from insurance companies.

Section 380 of the Canadian Criminal Code lays out the offence of fraud; it reads:

380 (1) Everyone who, by deceit, falsehood or other fraudulent means, whether or not it is a false pretence within the meaning of this Act, defrauds the public or any person, whether ascertained or not, of any property, money or valuable security or any service,

(a) is guilty of an indictable offence and liable to a term of imprisonment not exceeding fourteen years, where the subject-matter of the offence is a testamentary instrument or the value of the subject-matter of the offence exceeds five thousand dollars; or

(b) is guilty

(i) of an indictable offence and is liable to imprisonment for a term not exceeding two years, or

(ii) of an offence punishable on summary conviction, where the value of the subject-matter of the offence does not exceed five thousand dollars.

Minimum punishment

(1.1) When a person is prosecuted on indictment and convicted of one or more offences referred to in subsection (1), the court that imposes the sentence shall impose a minimum punishment of imprisonment for a term of two years if the total value of the subject-matter of the offences exceeds one million dollars.

Affecting public market

(2) Everyone who, by deceit, falsehood or other fraudulent means, whether or not it is a false pretence within the meaning of this Act, with intent to defraud, affects the public market price of stocks, shares, merchandise or anything that is offered for sale to the public is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years.

How Does the Crown Prove Insurance Fraud?

Like any crime, to obtain a conviction, the Crown must prove both that the accused committed an act prohibited by the Criminal Code and also that the individual intended to do so, or had a “guilty mind”. If you have been charged with fraud, the Crown must present evidence in court that proves that you have committed a prohibited act of falsehood, deceit or other fraudulent acts and that those acts caused deprivation of some kind. This deprivation can be a tangible loss or it can be an economic interest being put at risk. In addition, the Crown must prove that you were aware of the fraudulent acts you were committing. The Crown may alternatively prove that you were aware there was a risk associated with the actions you were undertaking and that despite knowledge of this risk you proceeded with the course of action anyway. In cases involving insurance fraud the Crown must also demonstrate that the insurance company was the party deprived of some economic interest.

What are the Consequences of Committing Insurance Fraud?

As with any criminal offence, being charged with fraud in relation to an allegation of insurance fraud is a very serious matter. If you have been charged with fraud due to an alleged false claim against your insurance company, it is important to contact qualified legal counsel immediately. Our Firm has experience handling insurance fraud cases and can guide you through the process in order to obtain the best possible outcome.

Financial Consequences

Aside from the criminal penalties that result from a fraud conviction (as outlined above in the section entitled “Fraud and the Criminal Code”), there are also possible financial implications. If an insurance company can prove that an insurance claim was made fraudulently they will automatically deny coverage on the claim. This leaves the cost of repairs for any damages or loss of property up to the accused to cover. Additionally, an insurance company may sue an accused for any damages that they may have incurred in relation to the fraudulent claim. Finally, insurance companies are likely to deny future coverage to an individual who has been convicted of an insurance fraud offence.

Employment Consequences

Being convicted of fraud in relation to a fraudulent insurance claim is a serious offence that could have serious implications on an individual’s employability. In today’s job market many employers require regular criminal background checks before they will employ anyone. Many employers are reluctant to hire an individual with a criminal record, particularly a record of fraud. The best approach is to be totally upfront about your criminal record from the outset.

Travel Consequences

Having a criminal record can affect an individual’s ability to travel outside Canada. Many foreign jurisdictions are reluctant to admit individuals with past criminal history. Particularly, the United States may refuse entry to those with criminal charges including fraud offences. A U.S. waiver may be required for travel in the U.S. to ensure entry.

Immigration Consequences

Citizenship and Immigration Canada require thorough background checks on everyone admitted to Canada as an immigrant or permanent resident. Having a criminal record can negatively impact your immigration or permanent residency and it is very likely that having a fraud conviction can exasperate the process and possibly cause the application to be denied.

How do Insurance Companies Combat Insurance Fraud?

Insurance companies generally have a rigorous system in place to combat insurance fraud. Larger companies often have entire departments related to the detection, prevention and prosecution of insurance fraud. This is done to keep costs down which in turn allows insurance companies to provide their customers with the lowest rates possible. As such, businesses will often prosecute those who are found to have committed insurance fraud to the fullest extent of the law.

Sunlife Financial

Sunlife financial is a multi-national insurance firm which provides group benefits as well as insurance to health care providers. Like other large insurance companies, Sunlife employs an experienced anti-fraud team whose main task is to detect, investigate and prevent fraud from occurring. Sunlife’s primary method of fraud detection and protection is data mining and the use of algorithms. Data mining refers to collecting and analyzing large amounts of data in order to uncover patterns in the way insurance claims are filed. This allows Sunlife to detect suspicious claims or patterns of claims. Claims deemed to be suspicious are then investigated further by a team of experts. Investigation techniques may include a full analysis of all of the business practices related to a company that filed an insurance claim and surveillance of individuals or businesses. Experts are able to report back to the system indicating which claims were in fact fraudulent and which were legitimate. This allows the anti-fraud system to become smarter over time, improving its overall accuracy.

If fraud is detected after the investigation, Sunlife will generally blacklist that individual or business, refusing to offer them any more insurance. Additionally, Sunlife will not pay out any claims that are found to be fraudulent, and will likely commence civil actions to recover any damages they may have incurred as a result of the fraudulent activity.

Manulife

Manulife is a large multi-national insurance company with offices all over the world. As such, they are some of the world leaders in insurance fraud detection, prevention and investigation. Manulife’s fraud prevention strategy is to detect and prevent insurance fraud before it even happens or at the very least in the early stages. They employ an experienced team of anti-fraud investigators who work to detect, combat and deter health care fraud and health care abuse as well as group benefits fraud.

Manulife has countless techniques for combating insurance fraud. They utilize a specialized anti-fraud system which is able to quickly and efficiently scan and analyze millions of insurance claims that have been submitted by various customers to determine which are legitimate and which are not. They are able to utilize data from archives they accumulate in order to flag changes in normal billing patterns as well as to monitor the rate at which health care providers prescribe narcotics. Manulife also employs a highly experienced team of consultants, anti-fraud experts, health care providers and law enforcement personnel to assist in analysing data on various claims. This skilled team is in charge of detecting and then investigating any potentially fraudulent claims they come across. In cases where they believe fraud has been committed, Manulife’s Business Integrity department would pursue a criminal prosecution of the accused as well as any potential civil action that will be taken. In addition to detecting and eliminating current insurance fraud, Manulife’s skilled anti-fraud team also consults on how to protect against further insurance fraud.

Great West Life Assurance Company

Great West Life Assurance Company is a Canadian insurance company offering various types of insurance to individuals all over Canada including group benefits. As with other large insurance companies, Great West Life employs a team of highly experienced anti-fraud analysists who work around the clock to detect, combat and prevent insurance fraud. Great Life Assurance uses many of the same anti-fraud techniques as other insurance companies including data mining, the use of algorithms and their experienced team of professionals. Data mining and algorithms are used to detect suspicious claims which are then forwarded to the anti-fraud team for further investigation. In addition, Great West Life Assurance also utilizes random auditing. For example, in 2013 Great West Life randomly audited approximately 180,000 customers who had submitted electronic claims, requiring the customers to submit receipts for the claims. Those who fail to comply with such an audit may have their ability to submit electronic claims suspended.

Once fraud has been positively detected by Great West Life’s experienced team of analysts, they will determine how best to proceed based on the specifics of the case. Responses may include demanding reimbursement for any claim that was paid out, filing a civil lawsuit against the individual who allegedly committed the fraud in order to recover damages, blacklisting the individual from being insured with Great West Life, or even forwarding the information to the police for formal criminal charges to be laid. All of these outcomes will have very serious impacts on the individuals life.

Green Shield Insurance Canada

Green Shield Insurance Canada is a Canadian insurance company offering supplementary health and dental insurance to Canadian’s. This coverage is designed to cover unexpected medical costs not already covered by the provincial government through universal health care. As with all large insurance companies, Green Shield strives to detect and prevent fraud before it occurs in order to protect customers from rising rates. To do this, Green Shield employs various tactics to detect fraud before it has begun, or in its early stages, to prevent it from becoming a larger issue. One of the ways Green Shield does this is through approvals and ratings of health care providers. Prior to listing a health care provider on their website or app, Green Shield will evaluate the provider to ensure they are in good standing with the government of whichever locale they are registered in. Once a healthcare provider has been approved and added to Green Shield’s website or app, their fraud department will continue to monitor the provider, flagging any suspicious claims. The provider will be given a rating by the fraud department, which will determine how future claims that are submitted by that provider will be handled. Healthcare providers with lower ratings will be scrutinized more harshly before any payouts will be made by Green Shield. This allows Green Shield to take a proactive approach to fraud prevention and stop it before it even begins. In addition, Green Shield also actively monitors the customary rates associated with various medical and dental procedures in order to reduce the number of exaggerated claims submitted by health care providers.

The Insurance Board of Canada

The Insurance Board of Canada is a government organization dedicated in part to investigating and preventing various types of insurance fraud in Canada. This includes educating the public on insurance fraud to ensure the public does not unwittingly commit an insurance fraud related offence as well as educating the public to be able to recognize insurance fraud when they see it and the importance of reporting it to the correct officials. The Insurance Board of Canada has an online reporting system that allows members of the general public to report insurance fraud that they believe has occurred. Once a report is filed by a member of the public the Insurance Board of Canada will investigate and determine if fraud has in fact been committed. In situations where they do discover fraudulent activity, the correct authorities will be notified.

How Insurance Fraud Investigations Begin

Is it Easy to be Accused of Benefits Fraud?

Being accused of committing insurance benefit fraud can be a stressful and unsettling experience. With advances in technology, many benefit users can now submit claims online without providing paper receipts up front. While online services make filing claims simple for users, they also make it possible for users to submit fraudulent claims and receive money that they are not entitled to. As a result, insurance companies have developed sophisticated techniques to screen claims and catch fraudsters.

In some cases, benefit users may be accused of committing benefit fraud even when they did not intentionally do so. For example, failure to accurately submit online claims could result in overpayment from the insurance company. This overpayment will be considered fraudulent.

Insurance benefit fraud investigations arise generally in one of four ways; the plan member is contacted directly by the insurance company, the plan member is contacted by their employer, the plan member is caught as part of a sting investigation, or the plan member is involved in a joint investigation involving both their employer and insurance benefit provider.

Plan Member Contacted by Insurance Company

With more and more online claims being accepted by insurance companies, insurance benefit fraud has become easier to commit. To combat this, insurance companies have developed sophisticated techniques to investigate potential fraud.

Insurance companies employ entire departments of employees dedicated to tracing and tracking down fraudsters. Fraud departments at insurance companies will work to verify claims submitted to ensure the claims were submitted accurately and that the benefit user was entitled to the benefits received. If the insurance company comes across a claim it cannot verify or a claim that is deemed fraudulent, it could trigger an audit, causing the insurance company to attempt to verify all claims submitted by the user.

The insurance company may contact the service provider to confirm services were rendered as claimed. If the service provider is unable to verify the claim, the insurance company will reach out to the benefit user to verify the claim. If the benefit user is unable to verify the claim, the claim will likely be deemed fraudulent.

If you have been contacted by your insurance benefit provider in reference to unverified claims, it is important to consult with legal counsel prior to communicating with the insurance company investigator. Any admissions made, or evidence provided could later be used against an accused in civil or criminal court.

Employer Ambush

In some cases, when insurance fraud allegations are leveled at an employee, the employer will become involved in the investigation. This is common where the fraud resulted in an employer loss rather than an insurance company loss. In these cases, it is common for the employer to call a meeting with the impugned employee in an attempt to solicit a confession.

In these scenarios, employees often feel compelled to participate in the employer investigation or risk employment consequences. However, in many cases the risk associated with cooperating with the investigation is greater than the risk of refusing. In almost all cases, if the employee has committed benefit fraud, they will be terminated regardless of whether or not they cooperate with the investigation. As a result, there is often no benefit to participating in any meetings with the employer. Any admissions made to one’s employer could later be used in court to gain a fraud conviction.

If you have been accused of employee insurance benefit fraud and have been asked to participate in a meeting to discuss the matter, it is important to consult with legal counsel prior.

Stings

Another common way individuals are caught committing employee benefit fraud is through sting investigations. Sting investigations may occur where a number of people are participating in an insurance fraud scheme. Such a scheme could involve several employees from the same organization all filing false claims for services from the same service provider. In these situations, the discovery of one fraudulent claim could lead to the discovery of many fraudulent claims from many different employees within one organization. Sting investigations often result in the termination of a large number of employees at one time.

Joint Investigations

In some cases, both the insurance company and the employer will investigate the potential benefit fraud in tandem. This may occur where both parties have experienced a loss as a result of the fraudulent behaviour. In a joint investigation the risk of the matter being reported to law enforcement increases since both the employer and the insurance company may report the allegations.

If you are found to have committed insurance benefit fraud, you risk losing your job, being held civilly liable or being arrested and charged criminally. If you are a regulated professional, you also risk being investigated and disciplined by your regulator. If you are being investigated for insurance benefit fraud or have been accused of insurance benefit fraud it is important to protect your rights from the outset of the investigation. The best way to protect yourself is to hire experienced legal counsel to guide you through the process. Donich Law has experience defending a variety of insurance fraud cases and regularly obtain favourable results for our clients.

Quick Facts

What is Insurance Fraud?

Insurance fraud is no different than any other fraud. For the most part insurance fraud is committed by group plan members who falsely claim expenses which were never rendered or are inaccurate. Sometimes the plan member will claim physiotherapy, massage therapy, chiropractor or psychotherapy expenses which were never rendered. These offences are on the rise because plan members can claim services online or on a mobile app without submitting physical receipts.

What are the Consequences for Insurance Fraud?

The consequences are serious and often include employment, regulatory or criminal sanctions. Many times employers will also conduct their own internal investigation upon being notified by the insurer. This information can then be passed off to regulators or the police for prosecution.

Will I loose my Job and get caught for Insurance Fraud?

Employment consequences are common because the employer is often the entity who is defrauded when the member falsely claims expenses. Like stealing from work, employers treat insurance fraud as a breach of trust. The police will consider the amount of evidence, witnesses statements, whether the fraud is an employer or insurer loss and if the crown can prove its case.

Does the Value of the Fraud matter?

No. Insurances companies prosecute plan members irrespective of the value, employers are the same. Allegations of insurance fraud can be as low as $100 or into the tens of thousands.

How far do Insurance Companies look back?

Although insurance companies often recommend plan members retain receipts for 12 months, in practice they can look back 5-7 years. The insurance companies will pull patient health records from providers who are required to retain this information under their regulatory rules and confirm whether the plan member received treatment.

How do people get Caught for Insurance Fraud?

Most times plan members are caught because of a random audit or a questionable expense. Once the member is on radar, the insurance company will then audit the entire claims history for false claims. The insurance companies will then contact plan providers to confirm the validity of claims.

What if I Pay back the Money?

Many people pay insurers back right away with the false hope of avoiding any consequences. For the most part this does not work because the insurances company has to explain to the employer the source of the refund or why premiums may be affected. Lawyers are often contacted at this point where it may be substantially more difficult to mount a successful defence.

What if I come Clean and Apologize right away?

Like criminal charges, generally an apology does not stop the prosecution. It might sometimes help reduce a sentence or penalty, but it rarely gets the person out of trouble entirely. This is often a mistake plan members make only to find they are left with very little defences because they have now admitted to the offence.

Health Insurance Benefits Fraud Lawyers