August 09, 2018

The Legal Standards for Insurance Fraud in Dallas

What is insurance fraud and how do lawyers defend it?



Fraud means using false statements or other types of deception in order to try to get money or property from someone else.. (1)

There are many cagtegories of fraud.  Some refer to the means of communications used, such as mail fraud (using the mail or an interstate carrier to commit fraud), or wire fraud (using interstate wire communications, like telephone, fax, email, texts, or computer routing to commit fraud).  Other categories refer to the subject of the fraudulent scheme, like bankruptcy fraud, securities fraud, and health care fraud.

Insurance fraud is one category of fraud that is very common.  It usually involves using false statements or deception to try to get an insurance company to pay a claim that they should not have to pay, or to pay more than they should have to pay.

 

Standards for Fraud

Before analyzing the specifics of insurance fraud, it’s important to understand the standards for fraud, so that it’s easier to apply them to the insurance industry.

Fraud always involves someone lying to or deceiving another person for the purpose of obtaining some kind of financial advantage or benefit that they wouldn’t be entitled to under normal circumstances.

Fraud also occurs when someone denies another person an item of value, even though the victim would otherwise be entitled to that item.

The elements needed for a charge of fraud by false statement include:

  • The accused lied or misrepresented a material fact
  • The accused knew that the fact was false
  • The accused intended for the victim to rely on the false information
  • The accused intended to use the false statement to obtain money or property from the victim

In many states, the prosecution must prove each element existed to secure a conviction.


What is Insurance Fraud?


According to the Texas Department of Insurance, companies, agents, adjusters, doctors, and hospitals, or consumers commit insurance fraud when they lie or misrepresent facts for financial gain. (2)


Studies estimated that insurance fraud costs taxpayers $150 billion each year, which means the average family pays an additional $700 in premiums to cover these losses.


In Texas, anyone that suspects another person has committed insurance fraud must report it within 30 days. The law protects people that report fraud within this time period from liability and retaliation.


Insurance fraud can occur in claims for personal injury, healthcare, life insurance, Workers’ Compensation, and residential mortgage applications.


Common types of insurance fraud include:

  • Auto – Filing claims for fake accidents, or filing claims for accidents that never took place
  • Health – Examples include medical professionals that inflate or fabricate aspects of their bills and workers that claim disability even though they are healthy
  • Life Insurance – Misrepresenting an insured’s health on an application, suspicious claims after the death of an insured
  • Workers’ Compensation – Filing a false claim, and remaining on Workers’ Comp even after recovery from injury
  • Mortgage – Borrowers that lie or mislead on their applications, agents that divert escrow funds to their own accounts

Insurance Fraud Defenses


There are several insurance fraud defenses that attorneys can use to help their clients fight these charges, including:

  • Truth – The allegedly false statement was actually true.
  • Lack of knowledge – This means that the defendant didn’t knowingly lie or make a false statement, but believed what was said was in fact true.
  • Lack of intent – This means that the defendant didn’t intend to make the claim, but some error or mistake caused the submission of the false claim. To prove this, the defense would have to provide evidence of how that mistake occurred.
  • Under Duress – This means that someone else forced the defendant to make the false claim under threat of violence.
  • Misinterpretation – Also known as the ‘ambiguous statement’ defense, lawyers can argue that the defendant’s statement of material facts was true, but that the victim misinterpreted or didn’t understand the statement correctly.

The strategy that a defense team chooses to use is based on the specific circumstances of each case, and the defense’s ability to provide evidence to back up the assertion.


Finding An Attorney for Fraud in Dallas


Regardless of whether someone is charged with insurance fraud or some other type of fraud, it’s a serious offense that can be prosecuted as a felony that results in jail time.


That’s why finding an attorney for fraud in Dallas is one of the first steps that a defendant should take after an arrest.


An experienced defense team can examine all the evidence and plan a course of action to ensure that a defendant’s rights are protected. In some instances, a plea negotiation is the best option, and in other instances, there is sufficient evidence to disprove a fraud charge.


Attorney John Helms

 

 


SOURCES

  1. http://www.acfe.com/fraud-101.aspx
  2. https://www.tdi.texas.gov/pubs/consumer/cb044.html
 
 

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