Disability & Health Care Fraud
As a reporting party, you have a legal obligation to refer insurance claims or transactions where you have reasonable belief that insurance fraud may have or might be occurring. Reasonable belief is defined as "a level of belief that an act of insurance fraud may have or might be occurring for which there is an objective justification based on articulable fact(s) and rational inferences therefrom."
After your claim/transaction has been referred to the California Department of Insurance (CDI), it will be reviewed by a supervisor to determine whether the claim/transaction should be:
- Assigned for investigation
- Referred to another agency
- Closed due to a lack of resources
- Closed due to a lack of evidence
When determining if a claim is viable to be assigned for investigation, the CDI supervisor will be evaluating the information provided from your referral. If there are questions, the CDI supervisor may contact you to ask additional questions. Your responses to the following questions are helpful when determining if a case rises to the level of an investigation:
- What facts caused the reporting party to believe insurance fraud occurred or may have occurred?
- If your allegation involves your insured working while receiving disability payments, what does the insurance policy say about this issue and how was the insured made aware of this (if at all)?
- What are the suspected misrepresentations and who it was that allegedly made them?
- Individual? Group? Organized ring?
- How is the alleged misrepresentation(s) material, how do they affect the claim or transaction??How is the alleged misrepresentation(s) material, how do they affect the claim or transaction?
Summarize the financial impact of the misrepresentation here and how it changed your decision on the claim or transaction. - Who are the pertinent witnesses to the alleged misrepresentation and what documentation exists?
- Include a statement as to whether or not the investigation is complete.