Skip to Main Content
Menu
Contact Us Search
CA Department of Insurance
CA Department of Insurance
CA Department of Insurance

Disability and Healthcare Fraud

Disability and Healthcare Insurance Fraud Program

Health insurance fraud is a significant problem for health insurance policyholders because it drains resources out of the system causing otherwise unnecessary premium increases. California Insurance Code section 1872.85(a) provides funding for the Disability and Healthcare Fraud Program through an annual special purpose assessment to be determined by the Commissioner: not to exceed 20 cents ($0.20) for each insured person in California who is covered by an individual or group insurance policy it issues. This funding supports criminal investigations statewide by the Fraud Division and prosecution by district attorneys for suspected fraud involving disability and healthcare.

This program area includes suspected fraudulent claims involving: claimant disability other than workers' compensation, dental claims, billing fraud schemes, immunization fraud, unlawful solicitation, durable medical equipment, and posing as another to obtain benefits.

During Fiscal Year 2020-21, the Fraud Division identified and reported 759 suspected fraud claims, assigned 98 new cases, and made 54 arrests and 36 referrals to prosecuting authorities. The potential loss of these cases amounted to $430,361,371.


District Attorneys' Disability and Healthcare Program

In Fiscal Year 2020-21, 10 counties received funding totaling $5,950,000 through the Department's Disability and Healthcare Insurance Fraud Grant Program. The district attorneys reported 292 investigations and 88 arrests, which also included a majority of Fraud Division arrests. District attorneys prosecuted 112 cases involving 188 defendants with chargeable fraud totaling $956,514,131, which resulted in 26 convictions and $51,348,502 in restitution ordered by the courts.


Disability Insurance Fraud Assessment Grant Program Regulations

Google Translate