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CA Department of Insurance

Insurance Fraud is a Felony


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Fraud Division Overview

Established in 1979, the Fraud Division is the law enforcement unit within the California Department of Insurance and is composed of four separate insurance fraud programs:

The Fraud Division Detectives are the leading experts in the field of insurance fraud.  They are trained in criminal investigations and provide assistance as well as training to consumers, the insurance industry, law enforcement agencies and the public/private sector.

Fraud Division Detectives are sworn peace officers.  They conduct investigations, surveillances, undercover operations and interview witnesses and suspects.  Detectives also write and serve search warrants; make arrests and testify in court.

Fraud Division Detectives are also assigned to various local enforcement task forces such as auto theft, computer forensics, underground economy, pharmaceutical fraud and disaster fraud. 

What is Insurance Fraud?

Fraud occurs when someone knowingly lies to obtain a benefit or advantage to which they are not otherwise entitled or someone knowingly denies a benefit that is due and to which someone is entitled. Referrals on suspected insurance fraud are handled by the California Department of Insurance (CDI) Enforcement Branch and may  be prosecuted as a felony. The punishment for committing insurance fraud ranges from probation, fines, community service, restitution, confinement in county jail and/or state prison. According to the law, the crime of insurance fraud can be prosecuted when:

 

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Insurance Fraud Costs Consumers

Although the incidents of insurance fraud are frequent and far reaching, its effect on the lives of the general public is seldom recognized.  Some of the effects of insurance fraud in California are:″ 

People who commit insurance fraud range from first time opportunists to organized criminal rings who conspire to steal millions of dollars from insurance companies and consumers, to professionals and technicians who inflate the cost of services or charge for services not rendered; to ordinary people who want to cover their deductible or view filing a claim as an opportunity to make a little money.  All lines of insurance are susceptible to fraud, but it is particularly prevalent in automobile insurance, healthcare, and workers' compensation.  

If you are solicited to commit insurance fraud, STOP!

Insurance Fraud is a felony punishable by up to five years in state prison and a $50,000 fine.

Common Insurance Fraud Schemes

In order to protect yourself from being a victim or an unwilling participant in insurance fraud, it is important to be aware of common insurance fraud schemes.

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Automobile Insurance Fraud

Automobile insurance fraud in California has historically taken several forms. The most common fraud schemes involve automobile property and automobile collisions.

Automobile Property

This type of fraud can involve dishonest auto body and repair shops and/or insurers who may employ a variety of illegal or questionable techniques including: 

It is always important for the consumer to carefully review all paperwork from an auto body repair shop in order to protect against potential fraud.

Automobile Collisions

Automobile fraud often involves organized criminal rings.  Stagedauto collisions follow several basic schemes including:

If you have been in an auto collision, be cautious of any unsolicited referral to an auto body shop, law office or medical office.  Consumers should also be cautious of any auto body or repair facility that makes referrals to medical or legal offices. Organized collision rings and "cappers" actively solicit others in the community to participate in "paper collisions." These collisions only exist on paper and generally innocent parties are not involved. Paper collisions have gained popularity among fraud perpetrators, as they are less dangerous from a bodily injury standpoint, and there is less likelihood of police involvement.

Workers Compensation Fraud

Workers’ compensation fraud schemes can range from staged injuries on the job to complex systems of medical billing for services that were never rendered. The following are some examples of the most common workers’ compensation fraud activities:

 

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Property, Life and Casualty Fraud

The Property, Life and Casualty Fraud Program handles criminal investigations involving staged commercial/residential burglaries, life insurance fraud (which includes murder for profit cases), fraudulent natural disaster claims (wildfire, flood, earthquake and wind), slip and fall claims, internal embezzlement cases, false food contamination claims, and false marine claims.  Criminal investigations in this program area can involve millions of dollars in loss (especially in life insurance fraud cases), multiple claims for the same loss and multiple suspects.

Disability and Healthcare Fraud

According to Section 1871(h) of the California Insurance Code, health insurance fraud is a particular problem for health insurance policyholders. Healthcare fraud causes losses in premium dollars and increases healthcare costs unnecessarily.

As mandated by California Insurance Code Section 1872.85(a), funding for the Disability and Healthcare Fraud Program is derived from an annual assessment not to exceed 20 cents annually for each insured under an individual or group insurance policy issued in the State.  This funding supports criminal investigations statewide by the Fraud Division and prosecution by district attorneys of suspected fraud involving disability and healthcare fraud.

This program area includes suspected fraud involving: claimant disability other than workers’ compensation, dental claims, billing fraud schemes, unlawful solicitation (usually associated with medically unnecessary surgery claims), durable medical equipment, and posing as another to obtain benefits.

The National Health Care Anti-Fraud Association reports that in the United States, over $2.5 trillion is spent on healthcare every year.  Of this amount, between three to ten percent is lost to fraud.

Billing of Medical Services

The majority of healthcare fraud is committed by a very small minority of dishonest healthcare providers—hospitals, physicians, dentists, pharmacies, etc., and includes questionable or illegal billing of medical services. 

The Fraud Division encourages consumers to review their Explanation of Benefits and to compare them to services actually received. 

The most common types of fraud committed by dishonest providers include:

 

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Reporting Suspected Insurance Fraud

Visit the CDI’s website at www.insurance.ca.gov to download and print a copy of the form  (Consumer Insurance Fraud Reporting Form) to report suspected fraud. Please complete the form thoroughly with as much detail and information as possible.  Reports of suspected insurance fraud may be made anonymously.

Completed  Consumer Insurance Fraud Reporting Form  and any attachments are to be mailed to the following address:

California Department of Insurance

Enforcement Branch Headquarters

Intake Unit

9342 Tech Center Drive, Suite 100

Sacramento, CA 95826

Filing a Complaint of Suspected Insurance Fraud  

Download a copy of the form (FD-1) to report suspected fraud. Please complete thoroughly with as much detail as possible.

Consumer Fraud Claims Form (sample)

FraudFormSample

Local Fraud Division Regional Offices Jurisdiction Map

CDIFraudMap

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Fraud Division Regional Offices

Notification of these types of fraud can be made in person or mailed to:

The California Department of Insurance
Post Office Box 277320
Fraud Division Intake Unit
Sacramento,CA 95827-7320

Regional Office Addresses:

Regional Office Address Counties Served
Benicia

1100 Rose Drive, Suite 100

Benicia, CA  94510

(707) 751-2000

Alameda, Contra Costa, Del Norte, Humboldt, Lake, Marin, Mendocino, Napa, San Francisco, Solano, and Sonoma
Fresno

1780 East Bullard, Suite 101

Fresno, CA  93710

(559) 440-5900

Fresno, Inyo, Kern, Kings, Madera, Mariposa, Merced, San Luis Obispo, and Tulare
Inland Empire

9674 Archibald Avenue,

Suite 100

Rancho Cucamonga, CA  91730

Phone: (909) 919-2200

Riverside and San Bernardino
     
Orange

333 South Anita Drive,

Suite 450

Orange, CA  92868

Phone: (714) 712-7600

Orange
Sacramento

9342 Tech Center Drive,

Suite 500

Sacramento, CA  95826

Phone: (916) 854-5700

Alpine, Amador, Butte, Calaveras, Colusa, El Dorado, Glenn, Lassen, Modoc, Mono, Nevada, Placer, Plumas, Sacramento, San Joaquin, Shasta, Sierra, Siskiyou, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo, and Yuba
San Diego

10021 Willow Creek Road,

Suite 100

San Diego, CA  92131

Phone: (858) 693-7100

Imperial and San Diego
Silicon Valley

18425 Technology Drive

Morgan Hill, CA  95037

Phone: (408) 201-8800

Monterey, San Benito, San Mateo, Santa Clara, and Santa Cruz

 

Southern Los Angeles

5999 East Slauson Avenue

City of Commerce, CA  90040

Phone: (323) 278-5000

Southern Los Angeles County
Valencia

27200 Tourney Road,

Suite 375

Valencia, CA  91355

Phone: (661) 253-7400

Northern Los Angeles County, Santa Barbara, and Ventura

 

The California Department of Insurance has a Consumer Hotline to serve the needs of the public.  If you have any information regarding fraudulent insurance activity, you may call the Consumer Hotline at 800-927- 4357.  All suspected insurance fraud reported to the Consumer Hotline is forwarded to the Fraud Division.

It is important to know that notification of insurance fraud may be made anonymously.  The Insurance Code states that no insurer, employees or agents of any insurer, shall be subject to civil liability for libel, slander or any other relevant cause of action by virtue of providing information, in good faith, concerning suspected insurance fraud to law enforcement, including the California Department of Insurance Fraud Division.

Talk to the Department of Insurance

Do you have a question, comment or concern? There are several ways to talk to us:

 

Call:

Call our Consumer Hotline at (800) 927-4357

Telecommunication Device for the Deaf dial (800) 482-4TTY

Telephone lines are open 8:00 AM to 5:00 PM Pacific Time, Monday through Friday, excluding holidays 

 

Write: 

California Department of  Insurance       

300 South Spring St., South Tower 

Los Angeles, CA 90013

 

Visit:

Visit us in person on the 9th Floor at the address above.

Office Hours: Monday through Friday8:00 AM to 5:00 PM Pacific Time, excluding holidays.

 

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