Fraudulent insurance act, committed, when–powers and duties of department–penalties.

375.991. 1. As used in sections 375.991 to 375.994, the term “statement” means any communication, notice statement, proof of loss, bill of lading, receipt for payment, invoice, account, estimate of damages, bills for services, diagnosis, prescription, hospital or doctor records, x-rays, test results or other evidence of loss, injury or expense.

2. For the purposes of sections 375.991 to 375.994, a person commits a “fraudulent insurance act” if such person knowingly presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, purported insurer, broker, or any agent thereof, any oral or written statement including computer generated documents as part of, or in support of, an application for the issuance of, or the rating of, an insurance policy for commercial or personal insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance, which such person knows to contain materially false information concerning any fact material thereto or if such person conceals, for the purpose of misleading another, information concerning any fact material thereto.

3. A “fraudulent insurance act” shall also include but not be limited to knowingly filing false insurance claims with an insurer, health services corporation, or health maintenance organization by engaging in any one or more of the following false billing practices:

(1) “Unbundling”, an insurance claim by claiming a number of medical procedures were performed instead of a single comprehensive procedure; (2) “Upcoding”, an insurance claim by claiming that a more serious or extensive procedure was performed than was actually performed; (3) “Exploding”, an insurance claim by claiming a series of tests was performed on a single sample of blood, urine, or other bodily fluid, when actually the series of tests was part of one battery of tests; or (4) “Duplicating”, a medical, hospital or rehabilitative insurance claim made by a health care provider by resubmitting the claim through another health care provider in which the original health care provider has an ownership interest.

The Full Statute can be Found Here.

The fraud allegations the insurance company makes are often unsupported. More often than not, what is termed fraud by the life insurance company, is mere oversights on the part of the policy holder.

          It is important you consult with an attorney immediately if the life insurance company is denying the claim based on alleged fraud. These claims can be hard to substantiate if you have an experienced attorney fighting on your side.