§ 704.051. Antifraud Plan Required for Certain Plan Issuers A plan issuer who collects direct written premium shall adopt an antifraud plan under this subchapter. § 704.001. Definition In this chapter, “plan issuer” means: (1) a health insurer, including a life, health, and accident insurer, a health and accident insurer, a health maintenance organization, and any other person operating under Chapter 841, 842, 843, 884, 885, 982, or 1501 who is authorized to issue, issue for delivery, or deliver insurance policies, certificates, contracts, or evidences of coverage in this state; (2) an approved nonprofit health corporation that holds a certificate of authority issued under Chapter 844; or (3) an insurer authorized by the department to write workers’ compensation insurance in this state. NOTE: Provision affects Life insurer’s, health insurer’s including HMO’s, disability insurer’s and worker’s comp insurer’s.
NOTE: The state does not require insurers to file their plans with the department. Only Utah-domiciled insurers will be asked to provide these plans, which will only occur during a normal audit. Plans need not be submitted outside of the normal audit process. 31A-31-112. Insurance Antifraud Plan. (1) An insurer, as defined in Section 31A-31-102, shall prepare, implement, and maintain an insurance antifraud plan for its operations in this state. (2) The insurance antifraud plan required by Subsection (1) shall outline specific procedures, actions, and safeguards that include how the authorized insurer or health maintenance organization will do each of the following: (a) detect, investigate, and prevent all forms of insurance fraud, including: (i) fraud involving its employees or agents; (ii) fraud resulting from misrepresentations in the application, renewal, or rating of insurance policies; (iii) fraudulent claims; and (iv) breach of security of its data processing systems; (b) educate employees of fraud detection and the insurance antifraud plan; (c) provide for fraud investigations, whether through the use of internal fraud investigators or third-party contractors; (d) report a suspected fraudulent insurance act, as described in Section 31A-31-103, to the department as required by Section 31A-31-110; and (e) pursue restitution for financial loss caused by insurance fraud. (3) The commissioner may investigate and examine the records and operations of authorized insurers and health maintenance organizations to determine if they have implemented and complied with the insurance antifraud plan. (4) The commissioner may: (a) direct any modification to the insurance antifraud plan necessary to comply with the requirements of this section; and (b) require action to remedy substantial noncompliance with the insurance antifraud plan.
CHAPTER 130. INSURANCE FRAUD § 4750. INSURER ANTI-FRAUD PLANS (a) Every insurer with direct written premiums shall prepare, implement, and maintain an insurance anti-fraud plan. Each insurer’s anti-fraud plan shall outline specific procedures, appropriate to the type of insurance the insurer writes in this state, to: (1) Prevent, detect, and investigate all forms of insurance fraud, including fraud involving the insurer’s employees or agents; fraud resulting from misrepresentations in the application, renewal, or rating of insurance policies; claims fraud; and security of the insurer’s data processing systems. (2) Educate appropriate employees on fraud detection and the insurer’s anti-fraud plan. (3) Provide for the hiring of or contracting for fraud investigators. (4) Report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud. (5) Where appropriate, pursue restitution for financial loss caused by insurance fraud. (6) Ensure that applicable state and federal privacy laws are complied with and that the confidential personal and financial information of consumers and insureds is protected. (7) Comply with such other procedures as the commissioner may require by rule. b) The commissioner may require an insurer to file annually its anti-fraud plan with the department and an annual summary of the insurer’s anti-fraud activities and results, including misclassification and miscoding. A workers’ compensation insurer shall file an anti-fraud plan with the department of labor, including information about fraud investigations, referrals, or prosecutions involving Vermont workers’ compensation claims, misclassifications, and miscoding, if requested by the commissioner of labor. Information regarding fraud investigations and referrals shall not be public unless the commissioner of labor or the attorney general commences administrative or criminal proceedings. (c) This section confers no private rights of action. This section does not affect private rights of action conferred under other laws or court decisions. (d) Enforcement. Notwithstanding any other provision of this title, the following are the exclusive monetary penalties for violation of this section. Insurers that fail to prepare, implement, maintain, or submit to the department of banking, insurance, securities, and health care administration an insurance anti-fraud plan are subject to a penalty of $500.00 per day, not to exceed $10,000.00. Sec. 3. 1 V.S.A. § 317(c)(36) is added to read: (36) anti-fraud plans and summaries submitted by insurers to the department of banking, insurance, securities, and health care administration for the purposes of complying with 8 V.S.A. § 4750.
Section 9 — Each insurer licensed to write direct insurance in this state shall institute and maintain an insurance antifraud plan. An insurer licensed on the effective date of this act shall file its antifraud plan with the insurance commissioner no later than December 31, 1995. An insurer licensed after the effective date of this act shall file its antifraud plan within six months of licensure. An insurer shall file any change to the antifraud plan with the insurance commissioner within thirty days after the plan has been modified. Section 10 — An insurer’s antifraud plan must establish specific procedures to: (1) Prevent insurance fraud, including internal fraud involving employees or company representatives, fraud resulting from misrepresentation on applications for insurance coverage, and claims fraud; (2) Review claims in order to detect evidence of possible insurance fraud and to investigate claims where fraud is suspected; (3) Report fraud to appropriate law enforcement agencies and cooperate with those agencies in their prosecution of fraud cases; (4) Undertake civil actions against persons who have engaged in fraudulent activities; (5) Train company employees and agents in the detection and prevention of fraud.” Section 11 — If after review of an insurer’s antifraud plan, the commissioner finds that the plan does not comply with section 10 of this act, the commissioner may disapprove the antifraud plan . . . Note: In 1997, HB 1002 exempted life and health insurers from anti-fraud plan requirements. Department Advisory: http://www.insurance.wa.gov/companies/anti-fraud-guidelines.shtml
Title 75 Sections 1811-1816 (Motor Vehicle Insurance Fraud) Section 1811 — Each insurer licensed to write motor vehicle insurance in this Commonwealth shall institute and maintain a motor vehicle insurance antifraud plan…. All insurers licensed … shall file within six months of licensure. All changes to the antifraud plan shall be filed with the department within 30 days after it has been modified. § 1812. Content of plans. The antifraud plans of each insurer shall establish specific procedures: (1) To prevent insurance fraud, including internal fraud involving employees or company representatives, fraud resulting from misrepresentation on applications for insurance coverage, and claims fraud. (2) To review claims in order to detect evidence of possible insurance fraud and to investigate claims where fraud is suspected. (3) To report fraud to appropriate law enforcement agencies and to cooperate with such agencies in their prosecution of fraud cases. (4) To undertake civil actions against persons who have engaged in fraudulent activities. (5) To report fraud-related data to a comprehensive database system. (6) To ensure that costs incurred as a result of insurance fraud are not included in any rate base affecting the premiums of motor vehicle insurance consumers. WORKERS COMPENSATION FRAUD PLANS Pennsylvania Administrative Code TITLE 31. INSURANCE PART VII. PROPERTY, FIRE AND CASUALTY INSURANCE CHAPTER 119. ANTI-FRAUD — STATEMENT OF POLICY ANTIFRAUD PLANS § 119.22. Institution and maintenance of anti-fraud plans (a) Section 1203 of the act (77 P. S. § 1040.3) requires insurers, as defined in section 1101of the act (77 P. S. § 1039.1), to institute and maintain an insurance anti-fraud plan. This requirement applies to a workers’ compensation insurer with workers’ compensation premium volume as of August 31, 1993. Workers’ compensation insurers which become licensed or commence a writing premium volume, or both, after August 31, 1993, should institute and maintain an anti-fraud plan within 4 months of commencing to write business. Maintenance of the anti-fraud plan includes its ongoing implementation and operation by insurers. Since a substantial number of workers’ compensation insurers also actively write motor vehicle insurance, the Department encourages insurers to merge their workers’ compensation anti- fraud initiatives into their established motor vehicle insurance anti-fraud plans established under 75 Pa.C.S. Chapter 18 (relating to motor vehicle insurance fraud). The content of each insurers’ workers’ compensation anti-fraud plan should reflect the following minimum requirements: (1) Policies and procedures established by the insurer to prevent workers’ compensation insurance fraud. The policies and procedures should cover all aspects of the insurer’s operation and recognize the wide variety of potential fraudulent activity. Procedures should address internal fraud, fraud involving the integrity and security of company data including electronic data processed information, fraud involving employees or company representatives, and fraud resulting from misrepresentation on applications and renewals for insurance coverage and claims fraud. Detailed information should be provided describing existing procedure manuals, internal policies, guidelines and employe training programs implemented by the insurer to prevent fraud. It is recommended that specific policies and procedures be either included in the anti-fraud plan or, if the policies and procedures are voluminous, appropriately summarized. (2) Policies and procedures established by the workers’ compensation insurer to detect and investigate possible insurance fraud in the claims process. Reference should be made to specific procedure manuals, internal policies, guidelines and training initiatives designed to detect fraud in the claims process. (3) Policies and procedures established by the insurer to report workers’ compensation insurance fraud to appropriate criminal law enforcement agencies, including procedures to cooperate with and monitor progress of the agencies in their fraud cases. (b) To facilitate the Department’s understanding of insurers’ administration of their anti-fraud procedures, insurers are encouraged to cover the following areas in their plans: (1) Organizational components involved in or affected by the policies and procedures, including key positions involved. (2) Roles and interrelationships of components as they relate to the policies and the procedures described. (3) Personnel resources involved and budget allocations to implement the anti-fraud policies and procedures. (4) Extra-company relationships with central claims data bases and criminal law enforcement authorities as they relate to the policies and procedures implemented for anti-fraud plans.
27-54.1-5. Insurer antifraud initiatives. — (a) Insurers shall have antifraud initiatives reasonably calculated to detect, report, prosecute and prevent fraudulent insurance acts, antifraud initiatives may include: (1) Fraud investigators, who may be insurer employees or independent contractors; or (2) An antifraud plan. (b) A person engaged in the business of insurance having knowledge or a reasonable belief that a fraudulent insurance act is being, will be or has been committed shall provide such information to the governmental unit responsible for investigation of such act, or if no such unit exists to the commissioner.
Chapter No. 356 – Enacted 2001 Legislative Session Section 12 (b) (1)(A) No later than six (6) months after the effective date of this act, all applications for insurance, and all claim forms regardless of the form of transmission provided and required by an insurer or required by law as a condition of payment of a claim, shall contain a statement, permanently affixed to the application or claim form, that clearly states in substance the following, or words to that effect: “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.” (1)(B) The lack of a statement required in this subsection does not constitute a defense in any criminal prosecution under Section 3 nor in any civil action under Section 3 or 4. (2) The warning required by this subsection shall not be required on forms relating to reinsurance. Fraud Plan/SIU Requirement Chapter No. 356 – Enacted 2001 Legislative Session Section 12 (a) Anti-Fraud Plans Within six months of the effective date of this legislation, every insurer with direct written premiums exceeding ten million dollars ($10,000,000) shall prepare, implement, and maintain an insurance anti-fraud plan. Each insurer’s anti-fraud plan shall outline specific procedures, appropriate to the type of insurance the insurer writes in the state, to: (1) Prevent, detect and investigate all forms of insurance fraud, including fraud involving the insurer’s employees or agents; fraud resulting from misrepresentations in the application, renewal or rating of insurance policies; claims fraud; and security of the insurer’s data processing system; (2) Educate appropriate employees on fraud detection and the insurer’s anti-fraud plan; (3) Provide for the hiring of or contracting for fraud investigators; (4) Report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud; and (5) Pursue restitution for financial loss caused by insurance fraud, where appropriate.
For workers compensation only. Section 56-47-112 requires insurers to prepare, implement, maintain and submit anti-fraud plans to the Department of Commerce and Insurance. “Each insurer’s antifraud plan shall outline specific procedures to: (A) prevent, detect and investigate all forms of insurance fraud, including fraud involving the insurer’s employees or agents; fraud resulting from misrepresentations in the application, renewal or rating of insurance policies, claims fraud; and security of the insurer’s data processing system; (B) educate appropriate employees on fraud detection and the insurer’s anti-fraud plan; (C) provide for the hiring of or contracting for fraud investigators; (D) report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud; and (E) pursue restitution for financial loss caused by insurance fraud where appropriate.”
Fraud prevention plans and special investigations units.
(a) Every insurer writing private or commercial automobile insurance, workers’ compensation insurance, or individual, group or blanket accident and health insurance policies issued or issued for delivery in this state, except for insurers that write less than three thousand of such policies, issued or issued for delivery in this state annually, and every entity licensed pursuant to article forty-four of the public health law except those entities with an enrolled population of less than sixty thousand persons in the aggregate and, except those entities licensed pursuant to sections forty-four hundred three-a, forty-four hundred three-c, forty-four hundred-d, forty-four hundred three-f and forty-four hundred eight-a of the public health law shall, within one hundred twenty days of the effective date of this amended section to be promulgated by the superintendent to implement this section, file with the superintendent a plan for the detection, investigation and prevention of fraudulent insurance activities in this state and those fraudulent insurance activities affecting policies issued or issued for delivery in this state. The superintendent may accept programs and processes implemented pursuant to section forty-four hundred fourteen of the public health law as satisfying the obligations of this section and regulations promulgated thereunder.
(b) (1) The plan shall provide the time and manner in which such plan shall be implemented, including provisions for a full-time special investigations unit and staffing levels within such unit. Such unit shall be separate from the underwriting or claims functions of an insurer, and shall be responsible for investigating information on or cases of suspected fraudulent activity and for effectively implementing fraud prevention and reduction activities pursuant to the plan filed with the superintendent. An insurer shall include in such plan staffing levels and allocations of resources in such full-time special investigations unit as may be necessary and appropriate for the proper implementation of the plan and approval of such plan pursuant to subsection (d) of this section.
(2) In lieu of a special investigations unit, an insurer may contract with a provider of services related to the investigation of information on or cases of suspected fraudulent activities; provided, however, that an insurer which opts for contracting with a separate provider of services, shall provide to the superintendent a detailed plan therefor, pursuant to requirements set forth in regulation by the superintendent.
(3) Persons employed by special investigations units as investigators or by an independent provider of investigative services under contract with an insurer shall be qualified by education or experience which shall include an associate’s or bachelor’s degree in criminal justice or related field, or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, or seven years of professional investigation experience involving economic or insurance related matters. For the purposes of evaluation of medical related claims insurers may employ or retain duly licensed or authorized medical professionals.
Notwithstanding these minimum requirements anyone employed as an investigator in a special investigation unit or by a provider of investigative services under contract to an insurer as of the effective date of this paragraph and who was also so employed on or before September tenth, nineteen hundred ninety-six may continue in such employment provided the insurer identifies such person in writing to the superintendent giving the date such employment began and a description of the person’s qualifications, employment history and current job duties. (
c) The plan shall provide for the following: interface of special investigation unit personnel with law enforcement and prosecutorial agencies and with the financial frauds and consumer protection unit of the department of financial services; (
2) reporting of fraud data to a central organization approved by the superintendent; (3) in-service education and training for underwriting and claims personnel in identifying and evaluating instances of suspected fraudulent activity in underwriting or claims activities; (4) coordination with other units of an insurer for the investigation and initiation of civil actions based upon information received by or through the special investigation unit; (5) public awareness of the cost and frequency of fraudulent activities, and the methods of preventing fraud; (6) development and use of a fraud detection and procedures manual to assist in the detection and elimination of fraudulent activity; and (7) the time and manner in which such plan shall be implemented and a demonstration that the fraud prevention and reduction measures outlined in the plan will be fully implemented.
(d) (1) A fraud detection and prevention plan filed by an insurer with the superintendent pursuant to this section shall be deemed approved by the superintendent if not returned by the superintendent for revision within one hundred twenty days of the date of filing. If the superintendent returns a plan for revision, the superintendent shall state the points of objection with such plan, and any amendments as the superintendent may require consistent with the provisions of this section, including, but not limited to, staffing levels, resource allocation, or other policy or operational considerations. An amended plan reflecting the changes shall be filed with the superintendent within forty-five days from the date of return. (2) If the superintendent has returned a plan for revision more than one time, the insurer shall be entitled to a hearing pursuant to the provisions of article three of this chapter and regulations promulgated thereunder.
(3) If an insurer fails to submit a final plan within thirty days after a determination of the superintendent after the hearing held pursuant to paragraph two of this subsection, or otherwise fails to submit a plan, or fails to implement the provisions of a plan in a time and manner provided for in such plan, or otherwise refuses to comply with the provisions of this section, the superintendent may:
(i) impose a fine of not more than two thousand dollars per day for such failure by an insurer until the superintendent deems the insurer to be in compliance; or
(ii) impose upon the insurer a fraud detection and prevention plan deemed to be appropriate by the superintendent which shall be implemented by the insurer; or
(iii) impose the provisions of both subparagraphs (i) and (ii) of this paragraph.
(e) Any plan, the information contained therein, or correspondence related thereto, or any other information furnished pursuant to this section shall be deemed to be a confidential communication and shall not be open for review or be subject to a subpoena except by a court order or by request from any law enforcement agency or authority. For purposes of this section, the term “policies” shall refer to individuals covered if coverage is issued on a group basis.
(g) Every insurer required to file a fraud prevention plan shall report to the superintendent on an annual basis, no later than March fifteenth, describing the insurer’s experience, performance and cost effectiveness in implementing the plan, utilizing such forms as the superintendent may prescribe. Upon consideration of such reports, the superintendent may require amendments to the insurer’s fraud prevention plan as deemed necessary.
Regulation. Section 86.4 (a) All applications provided to applicants for commercial insurance and all claim forms for insurance, except personal automobile insurance, delivered to any person residing or located in this State on and after February 2, 1994 in connection with commercial insurance policies to be issued or issued for delivery in this State shall contain the following statement: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.” (b) All claim forms for personal automobile insurance delivered to any person residing or located in this state on and after February 2, 1994 in connection with policies of personal automobile insurance and claims arising under policies of such insurance shall contain the following statement: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or state claim for each such violation.” (c) Self insurers may adopt one or both of the required warning statements set forth in (a) or (b) (d) Location of warning statements and type size. (1) The warning statements required by subdivisions (a), (b) and (d) of this section shall be placed immediately above the space provided for the signature of the person executing the application or claim form and shall be printed in type which will produce a warning statement of conspicuous size. On claim forms which require execution by a person other than a claimant, or in addition to the claimant, the warning statements required by subdivisions (a), (b) and (d) of this section shall be placed at the top of the first page of the claim form or on the page containing instructions, either in print, by stamp or by attachment and shall be in type size which will produce a warning statement of conspicuous size. (2) Notwithstanding the provisions of paragraph (1) of this subdivision, insurers may affix the warning statements required by this Part to all applications and claim forms by means of labels and/or stamps or by attachment during the period February 2, 1994 to July 31, 1994. (e) Notwithstanding the provisions of subdivisions (a) or (b) of this section, insurers may use substantially similar warning statements provided such warning statements are submitted to the Insurance Frauds Bureau for prior approval.