Criminal Defense Attorneys Defending Individuals Accused of a Health Insurance Fraud Offense
Health Insurance fraud in Los Angeles County has been a major problem for insurance companies for many years.
As a result, millions of dollars have been lost and a new emphasis has been put in place on prevention and criminal prosecution of heath insurance fraud cases.
If you falsify information related to health insurance which results in obtaining payments that you are not entitled to, you could face prosecution for insurance fraud.
In California, health insurance fraud is a white collar crime and covered under Penal Code Section 550(a).
Insurance fraud is defined as:
- knowingly presenting an insurance claim that;
- contains false or misleading information with;
- the specific intent to obtain some benefit from an insurance company.
Our criminal lawyers also defend physicians accused of medical insurance fraud in California.
A common version of Medi-Cal fraud is the submission of claims for reimbursement from the program for health benefits which were never actually delivered.
If you are under criminal investigation or already charged with health insurance fraud, contact a Los Angeles criminal defense lawyer at Eisner Gorin LLP immediately.
Do not make any statements to Los Angeles police detectives as you may incriminate yourself. Remain silent.
Our defense attorneys need to review all the details and circumstances of your case in order to start preparing an effective strategy to defend you.
Health Insurance Fraud can describe any number of fraudulent activities from lying on an insurance application to receiving benefits for a falsely claimed disability.
The victim may be a private insurance company which was wrongfully obligated to pay benefits or it may be the government itself, through a program such as MediCal.
Common Health Insurance Fraud Cases
California Penal Code 550 prohibits fraudulent conduct with respect to many different types of insurance.
As you will see below, health insurance fraud is broken down into separate code sections, each targeting a specific type of criminal activity.
These subsections are commonly charged in connection with health insurance in Los Angeles County.
See related: Auto Insurance Fraud. For more detailed information about your specific case, call a Los Angeles criminal defense attorney at our office.
California Penal Code Section 550(a)(1) makes it a crime to:
- “knowingly present or cause to be presented any false or fraudulent claim for the payment of a loss or injury, including payment of a loss or injury under a contract of insurance.”
This describes what most people would think of when hearing the term health insurance fraud; namely, claiming benefits under a health insurance plan for an injury which is illegitimate.
For example, submitting a claim for benefits under a policy which protects the insured against injuries on the job when the injury in fact occurred at home would constitute fraud.
California Penal Code Section 550(b)(1) makes it unlawful to:
- “present any statement as part of, or in support of or opposition to, a claim for payment knowing that the statement contains any false or misleading information concerning any material fact.”
While Penal Code Section (a)(1) criminalizes the act of fraudulently claiming benefits, this section additionally penalizes the making of false or misleading statements in the attempt to claim the improper benefits.
For example, where an insured individual provides knowingly false statements on a questionnaire from an insurance company regarding their policy, they may be subject to criminal charges under this code section.
California Penal Code Section 550(b)(3) makes it a crime to:
- “conceal, or knowingly fail to disclose the occurrence of, an event that affects any person's initial or continued right or entitlement to any insurance benefit or payment, or the amount of any benefit or payment to which the person is entitled.”
Here, the criminal conduct is failing to disclose important information about the insured's eligibility for benefits.
For instance, consider a policy which entitles the insured to continued benefits only so long as they are unable to work. If that individual, through medical treatment or otherwise, regains the ability to work and they withhold that information from the insurer while continuing to receive payments, they may be charged under this code section.
A conviction for violation of California Penal Code Section 550(a)(1) is a felony offense punishable by imprisonment in the state prison for
- two to five years, and
- a fine not exceeding $50,000, or
- double the amount of the fraud, whichever is greater.
A conviction for violation of Penal Code Sections 550(b)(1) or (b)(3), if filed as a felony, is also punishable by imprisonment in state prison for two to five years, or by a fine not exceeding $50,000, or double the amount of the fraud, whichever is greater, or by both that imprisonment and fine.
If filed as a misdemeanor fraud case, the violations are punishable by imprisonment in Los Angeles County jail:
- not to exceed one year, or
- a fine of not more than $10,000, or
- by both that imprisonment and fine.
These fraud crimes are considered “wobblers,” as the Los Angeles County prosecutor has discretion to charge them as either misdemeanors or felonies cases.
This charging decision will usually depend on the amount of the alleged losses to the government or the insurer.
There are several factual and legal defenses which are often worth exploring by an experienced Los Angeles criminal defense lawyer in health insurance fraud cases.
First, it may be possible to prove that the injury or loss which the prosecutor is claiming is fraudulent is in fact legitimate.
This might be accomplished through medical records or the testimony of a medical expert. Even if the Los Angeles County prosecutor can establish that your injury did not render you eligible for benefits, our criminal defense attorneys might argue that you lacked the requisite knowledge that your claim was improper to be guilty of fraud.
This mental state defense can apply to all of the subsections described above.
Finally, the statute of limitations and the “discovery rule” established in the Zamora line of cases may provide you with an affirmative defense if the insurance company had sufficient facts to suspect you of fraud and did not act promptly.
Call our Los Angeles criminal defense law firm for more information.
Health Insurance Fraud Case Example
The following example comes from a real case litigated by the Los Angeles criminal defense attorneys at Eisner Gorin LLP.
Our client took out a disability insurance policy to protect her income from her primary occupation as a medical technician.
Soon after, the client suffered a serious injury on the job which prevented her from working. Client submitted a claim to the insurance company and began receiving benefits under the policy.
Some years later, the insurance company discovered that client was the owner and manager of a series of home healthcare businesses servicing the developmentally disabled.
Over the course of several years, the insurance company sent questionnaires and placed phone calls to client demanding details about these businesses, which client regarded as investments, not an occupation.
Finally, after over a decade of paying benefits, the insurance company accused our client of defrauding them. The Los Angeles County prosecutor charged our client with multiple counts of insurance fraud and grand theft for her responses to the insurance company's inquires as well as the boxes ticked on her original policy application.
Following the preliminary hearing, our Los Angeles criminal lawyers successfully moved to dismiss the insurance fraud counts for violating the statute of limitations.
The insurance company argued they knew everything they were now alleging as fraud years before taking any action or ceasing the payment of benefits. The court agreed, and the charges were dismissed.
Contact a Los Angeles Health Insurance Fraud Attorney
One of the most frightening aspects of being a defendant in a fraud case is the potential harsh legal penalties. A conviction can be life-changing and impact your future opportunities for many years.
Furthermore, most white collar crime defendants have no prior experience with the Los Angeles County criminal justice system and unknowingly make incriminating statements to investigators early in the legal process.
An accusation of fraud, let alone a conviction, can wreak havoc with your professional and personal life. Early and aggressive legal representation is often critical in the outcome of fraud cases.
Once you have been accused of health insurance fraud, its very important to seek help from an experienced Los Angeles criminal defense attorney at Eisner Gorin LLP.
Every case of insurance fraud is fact-specific and involves careful review of all of the relevant documents. If you or a family member has been accused of health insurance fraud, seek advice from our criminal defense law firm in Los Angeles as soon as possible.
Call our criminal lawyers to review your case at 877-781-1570.