Insurance fraud involves obtaining a settlement through an insurance policy by knowingly and unlawfully falsifying information.
Common types of insurance fraud include; inflating existing claims (exaggerating the extent/seriousness of the injuries), misrepresenting facts on an insurance application (value of an asset or health condition of an insured), submitting claims for non-existing injuries and staging accidents for the purpose of recovery.
In order to qualify as insurance fraud the above misrepresentations have to be done 1. knowingly, 2. willfully, 3. for the purpose of obtaining a settlement from the insurance company and 4. the insurance company has to rely on the misrepresentation. Innocent omissions on an application form or good faith miscalculations as to asset value do not amount to fraud.
The federal government is increasing its involvement in the prosecution of insurance fraud. The field however is still predominantly covered by state anti-fraud and insurance laws. These state statutes generally distinguish between “soft” and “hard” fraud. Soft fraud is defined as harmless little white lies told by insureds regarding their physical condition, extent of injuries or value of property. Hard fraud on the other hand involves staging accidents, faking one’s death and arson committed for insurance recovery purposes. The severity of punishment depends on whether the particular fraud at hand is considered to belong into the soft or hard fraud category.
Penalties for insurance fraud under state law include jail time, fines, probation, parole, restitution and community service depending on the amount of recovery obtained by fraudulent means.
On the federal level the most significant piece of legislation on the topic is IFPA the Insurance Fraud Prevention Act. IFPA was enacted in 1994 and it impacts everyone working for, affiliated with or appointed by an insurance company. It is important to understand that whereas state laws govern fraudulent activities of insureds IFPA governs people working in the insurance industry such as directors, insurance brokers, agents, officers and representatives. The Act lays out fraudulent behavior by these officers and directors and, among other things, prohibits convicted felons from working in and being hired by insurance companies. Penalties under IFPA predominantly consist of fines.