An individual who commits insurance fraud, including employee health benefits fraud, will be charged with fraud pursuant to section 380(1) of the Criminal Code. Insurance fraud can refer to anything from slightly increasing the amount paid on a benefit insurance claim to intentionally causing a significant accident in an attempt to collect insurance money. People who alter receipts when submitting claims have also committed the offence of utter forged documents.
A person commits fraud when they use deceit or false pretence to take money, property, a service or any other valuable security from a person, a business, or the public. Fraud offences are categorized based on the value of the fraud. If a person commits fraud valued at more than $5,000, they will be charged with fraud over $5,000. The penalties for this offence are more severe. If a person commits fraud valued at less than $5,000, they will be charged with fraud under $5,000 and will face less serious penalties.
Person A has health benefits through their employer. Person A submits false claims for health care services they did not receive and collects money from their insurance company for those services.
Person A intentionally crashes her car to collect insurance money for the vehicle. Person A collects money from her insurance company for the accident and is later arrested.
R. v. Mills, 2022 ONCA 404
In R. v. Mills, the accused, a tow truck driver, was convicted of one count of fraud over $5,000 after he staged a collision with another driver to collect insurance money. After the insurance claims had been submitted, police investigated the matter further and determined the accident was intentionally staged by the individuals. Both parties insurance companies suffered a loss.
Ontario College of Teachers v. Syed, 2020 ONOCT 138 (CanLII)
In Ontario College of Teachers v. Syed, the Member was prosecuted by the Ontario College of Teachers for employee health benefits insurance fraud. The College began the proceedings against the impugned Member, a teacher, after it was discovered that she had been submitting false claims under her employee health benefit plan.
In addition to being criminally charged with fraud over $5,000, the Member was found guilty of professional misconduct. The Member’s license to teach was suspended for a period of 12 months and she was ordered to complete course work and appear before the College to receive a reprimand. The College noted that while the professional misconduct was unrelated to the offender’s job as a teacher, the behaviour tarnished the reputation of the profession as a whole.
College of Nurses of Ontario v. Belcena, 2022 CanLII 135264 (ON CNO)
In College of Nurses of Ontario v. Belcena, the Member, a registered nurse, was prosecuted by the College of Nurses of Ontario for abusing her employee health benefit plan. The Member pled guilty to forging receipts and submitting false claims under her employee health benefit plan, totalling over $30,000.
The College found the Member guilty of professional misconduct indicating that she had “engaged in conduct that would reasonably be regarded by members of the profession to be unprofessional and dishonourable”. The College ordered the Member to appear before it to be reprimanded, suspended her teaching license for a period of five months, and ordered her to complete course work.
Offence Specific Defences
Lack of Intent
To prove that an accused has committed fraud, the Crown must prove that the accused intentionally used deceit or false pretence to defraud another party. If the accused had no intent to commit fraud, they cannot be convicted of fraud.
For example, person A purchases what they believe are authentic designer handbags from person B. Person A sells the bags, claiming they are authentic, to person C. Person C discovers the bags are knockoffs and believes person A has defrauded them. In reality, person A was tricked into believing the product was authentic. The only individual guilty of fraud in this scenario is person B who knew the handbags were knockoffs.
No Risk of Loss
To be convicted of a fraud charge, the Crown must prove that the victim suffered a loss or was at risk of suffering a loss. If there was no real risk of loss to anyone, the accused has not committed an offence but may be convicted of another.