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Insurance Fraud

What is Insurance Fraud?

  • Insurance fraud is the intentional submission of a false or deceptive statement to an insurance company for financial gain. 
  • According to the National Insurance Crime Bureau, insurance fraud is the second most costly white-collar crime in America. 
  • The Coalition Against Insurance Fraud estimates $80 billion dollars is lost each year as a result of fraudulent claims submitted to insurance carriers. It is believed insurance fraud costs the average U.S. family between $400 - $900 a year in the form of increased insurance premiums.

Who Commits Insurance Fraud?

  • Insurance Agents
  • Consumers
  • Attorneys
  • Contractors
  • Members of Organized Crime
  • Business Entities
  • Healthcare Providers

Role of the ODI Fraud & Enforcement Division

  • The Superintendent of Insurance is responsible for seeing that all insurance laws are enforced. In order to effectively investigate allegations of agent misconduct and insurance fraud, the Ohio Department of Insurance’s Fraud Division was created.
  • The division is designated as a criminal justice agency and is authorized to subpoena testimony and information, access law enforcement databases, and share confidential information with other regulatory and law enforcement organizations.
  • Division investigators work with federal, state and local law enforcement agencies, prosecutors and government entities to bring charges against insurance agents, consumers, health care providers and contractors who commit insurance fraud or engage in crimes associated with insurance.

Common Schemes

  • An individual files a false claim for an event, such as a burglary, accident, or skip/fall.
  • An individual intentionally damages or sets fire to their home or automobile to make it appear as if they have a legitimate claim.
  • A contractor intentionally damages a consumer’s roof or siding and claims it as storm damage in order to justify the need for repairs.
  • Individuals stage or intentionally cause an automobile accident.
  • A medical provider files a health insurance claim for an x-ray, office visit, or test they never provided.

Inflated Insurance Examples

  • An individual claims a 60-inch flat-screen TV was destroyed in a house fire when they only owned a 32-inch TV.
  • A homeowner claims $1,000 was stolen during a burglary when in reality it was only $100.

What Happens When You Report Insurance Fraud?

If you suspect someone has committed insurance fraud, contact the Ohio Department of Insurance immediately. Referrals can be made anonymously and the law protects those who report fraud from civil liability in the absence of fraud or bad faith.

Individuals who commit insurance fraud may face criminal prosecution. In addition to facing legal fees, fines, and a wide range of personal and professional consequences, an individual may be ordered to serve time in jail and even to repay the insurance company all of the money illegally received. 

While investigating an insurance fraud allegation, it is common for investigators to obtain evidence to support that an individual has also committed other crimes such as arson, falsification of documents, theft, forgery, money laundering, mail/wire fraud and/or telecommunications fraud.