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Insurance Fraud

Insurance Fraud is normally investigated by the Arizona Department of Insurance (ADOI), Fraud Unit. At the Federal level, it is often prosecuted under RICO (the Racketeering Influencing Corrupt Organization Act) or pursuant to Mail, Bank and Wire Fraud statutes. Arizona utilizes Arizona Revised Statute ARS 20-463 entitled “Insurance Fraud”, or ARS 13-2310 entitled “Fraudulent Schemes.”

Per ARS 20-463, Insurance Fraud, whether in Phoenix, or anywhere in Arizona, this crime occurs when a person presents a statement containing false information regarding any aspect of their insurance claim in an attempt to be paid money that does not belong to them, or in order to avoid making a payment to their insurance. Per ARS 13-2310, Fraudulent Schemes, whether in the Phoenix area, or anywhere in Arizona, this crime occurs when a person attempts to obtain an Insurance Benefit by any means of Fraudulent or false pretenses, promises, representations, or material admissions.

Insurance Fraud includes the following types:

  • Auto Insurance Fraud (such as staged accidents),
  • Life Insurance Fraud,
  • Health Insurance Fraud,
  • False Reimbursement Claims/Unemployment Fraud,
  • misrepresentations, including Medical Billing Fraud,
  • Property and Casualty Insurance Fraud, and
  • Workers Comp or Benefits Fraud.

If your case involves more than standard Insurance Fraud, and it potentially includes the elements of Benefits Fraud (AHCCCS, SNAP, Unemployment, Workers Comp, TNAF (Cash Assistance Fraud), Childcare Assistance or Disability Development Assistance Issues, then click here for “Benefits Fraud.”

Click Here for Benefits Fraud

POSSIBLE PUNISHMENT

If the case is charged under ARS 20-463 for Insurance Fraud, then it can be punished as a Class 6 Felony. A Class 6 Felony can include Probation with zero days jail – up to one year in jail; or prison time of 6 months up to 2.25 years in prison.

If the case is charged under ARS 13-2310, “Fraudulent Schemes”, then a person can be sentenced to Probation with zero days jail – up to one year in jail, or prison time of 3 years minimum, up to 12.5 years in prison. This is possible only if there is no prior Allegeable felonies on the person’s record. In addition, if the amount of the Fraud is above $100,000, the prosecutor can file a mandatory sentence Enhancement that requires a “prison only” disposition.

WARNING: If the amount is $100,000 or greater, there is a statutory sentence Enhancement which requires that prison time (and not probation with jail) be imposed. Many times we are able to have this Enhancement dropped during the plea negotiation phase, and we have had many clients with allegations of over $1,000,000 who have been sentenced with probation and zero days in jail.

POSSIBLE DEFENSES

The most common defense for Insurance Fraud is “Misunderstanding” or “Misinterpretation” of the insurance documents and benefits forms. Many times, forms utilized for various types of benefits (such as Unemployment, Health Insurance, Workers Comp, etc.) can be very confusing. Often, people do not realize that they are answering the questions contained on the form incorrectly. In other words, there was no intentional Fraud involved. It is up to us to show the Detectives and/or Prosecutors that this is the case.

The same can occur when applying for benefits or cashing out life insurance policies. With property and casualty insurance claims forms, many times the insurance company will deny the claim in “bad faith”, in order to avoid paying any money. If the dispute becomes contentious, they can claim that the person is engaging in Fraud. It is important that you have a skilled Insurance Fraud Defense Lawyer by your side to fight these insurance companies. The same is true of auto insurance/car accident claims. The most complex of all claimed Insurance Fraud cases involves Health Insurance claims and Medical Billing Fraud. Those can be much more complex. Once again, it is important to have an experienced Criminal Law Specialist review these types of allegations.

Additionally, because our law firm fights convictions from all angles, we would assert a wide range of defenses and challenges regarding constitutional violations which can apply in all criminal cases.  The possibilities are numerous and diverse.  One of those that we frequently assert is a “Miranda Rights Violation.”  In Arizona, the standard of whether any incriminating statement, (i.e., a statement which intends to admit guilt) is only admissible into evidence based upon a “voluntariness” standard.  If we can demonstrate that the police coerced you (i.e., intimidated or tricked you) into making a confession or an inculpatory statement, or that they did not properly read your Miranda rights, then we can suppress those statements and have any evidence gathered as a direct result of those statements.  In addition, “Denial of Right to Counsel,” is another common defense which is often raised.  This occurs when a suspect is in custody and requests to speak to their attorney, but is denied that request and the questioning continues.

Other defenses which can be used in more serious cases may include challenging the validity of any search warrant, or whether there were any “forensic flaws” during the investigation of your case.  Depending on what else you have been charged with, this could include exposing flawed procedures regarding computer analysis/cloning hard-drive procedures; forensic and financial accounting reviews; etc.

Lastly, one of the most common defense tactics is exposing sloppy or misleading police reports which include everything from misstatements, false statements, flawed photo lineups, and witness identification procedures.

PRE-INDICTMENT/PRECHARGE STAGE

Once an allegation has been made, or an investigation has begun, it is important to get DM Cantor involved as quickly as possible. Many times we are able to contact the Assistant U.S. Attorney or Federal Investigator to stop them from proceeding to a Criminal Indictment. If we can utilize Forensic Accountants to go back and “trace” where the assets went, it may be possible to show that it was not the defendant who actually took the items, but somebody else who is attempting to cover up for it.

Many times, we are able to show that the misappropriation was Unintentional. This could be due to a miscommunication or a misunderstanding of the job duties or the law. If the items or money can be returned, or in an agreement to return them over time can be reached, then it is often quite possible to keep charges from being filed.

Another defense has to do with what is known as “Sloppy Bookkeeping.”  This occurs when the employee or bookkeeper doesn’t know to property maintain balance sheets or profit and loss statements. If the mistakes can be undone, and property can be returned, it is often possible to resolve these cases with a “civil resolution.”

Click Here for Pre-Charge / Pre-Indictment Stage

It is important to hire the right Insurance Fraud defense attorney in order to have your charges dismissed.  Our firm has handled numerous cases such as these and we have had them successfully defended throughout Arizona.  Visit our case victories pages and click on Insurance Fraud in order to view our most recent successes.

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