Insurance fraud involves getting money or benefits from any type of insurance transaction through lies or misrepresentations. Anyone involved in the insurance process can commit insurance fraud, from insurance companies to consumers and doctors or mechanics to adjusters. However, this article focuses on the crime of insurance fraud from the perspective of consumers.
The Wisconsin insurance fraud law covers both insurance and employee benefit program claim frauds in one statute. The main provisions of this law are outlined in the table below.
Wisconsin Statute Section 943.395 - Fraudulent Insurance and Employee Benefit Program Claims
What is Prohibited?
It's a crime in Wisconsin to knowingly:
- Present a false or fraudulent claim or proof supporting a claim to be paid under an insurance contract
- Prepare a false or fraudulent account, statement, proof of loss, etc, knowing it'll be used to support an insurance policy claim
- Present a false or fraudulent claim or proof supporting a claim or information to affect a future claim for an employee benefit program
- Make any misrepresentation on an application for membership or to gain membership or a non-insurance benefit for oneself or another from a fraternal benefit society, such as Catholic Financial Life, Knights of Columbus, Sons of Norway, or Thrivent Financial for Lutherans.
Insurance fraud is a Class A misdemeanor if the value of the claim or benefit received is $2,500 or less. However if the claim or benefit is over $2,500, it's a Class I felony. Note that the value of the claim refers to the entire claim and not only the portion that was false or fraudulent. Class A misdemeanors (the most severe misdemeanor) can be punished by up to 9 months in jail and a fine up to $10,000 whereas Class I Felonies (the lowest felony) can be punished by up to 3.5 years in prison and a fine up to $10,000.
In addition, if your insurance company discovers you have lied on an application or in a claim then it can cancel your policy.
Examples of Insurance Fraud
Insurance fraud can be perpetrated with almost any type of insurance. Some examples of insurance fraud are:
- Vehicle Insurance and Accidents - Faking or exaggerating a car accident or injury to get money or services covered by an insurer, staging car accidents, or accepting checks for small accidents without fixing the vehicle
- Insurance for your Home or Rental - Exaggerating damage to your home or personal effects to receive a larger insurance reimbursement or seeking reimbursement for items that were neither lost nor stolen
- Small Business Insurance - Lying about circumstances around a customer slip and fall claim or arson of the building containing a failing business to not go bankrupt
- Insurance Applications - Misrepresenting personal medical history to qualify for life insurance
- Health Insurance, Medicare, or Medicaid Claims - Providing medical procedures that aren't needed or billing for services or supplies never provided to a client
- Disability Insurance Benefits - Claiming an injury is more serious than it is and therefore can't work to receive disability benefits
- Unemployment Insurance - Getting UI benefits when you are working under the table
- Workers' Compensation - Claiming you suffered an injury while on the job that you didn't suffer at all or were injured while not at work, or for employers, understating the number of employees or type of work they do is workers' comp fraud
Insurance Fraud Enforcement Agencies
The agency to contact to report insurance fraud varies based on the type of fraud. If you've witnessed or been victimized by insurance fraud, contact the relevant agency listed below:
- To file a complaint about an insurance company, use the online complaint form with the Office of the Commissioner of Insurance. Questions? Call them at 1-800-236-8517.
- If you think you were billed for medical services or supplies that you never got and use Medicare, call your Medicare plan provider to tell them about the fraud. If you aren't comfortable doing that, you can report suspected Medicare fraud at 1-800-Medicare.
- If you saw a licensed professional (for example, a doctor, therapist, or chiropractor) and believe he or she committed insurance fraud, you can also file a complaint with the relevant professional licensing board.
- To report suspected Workers' Compensation fraud, contact the Department of Workforce Development at 608-261-8486 or email@example.com.
- If you are aware of Unemployment Benefit fraud, contact the UI Fraud Hotline at 1-800-909-9472 (Monday to Friday 8 am to 4 pm) or complete the fraud reporting form online.
If you're charged with an insurance fraud crime, you should consult an experienced Wisconsin criminal defense attorney. If you have other questions about your insurance options, you may wish to call an insurance lawyer.