Insurance Fraud Definition – Different Types and What Constitutes Abuse

Your budget gets tighter because of the month. You ought to earn extra income — fast. Like you’d be good at.

Wait so you sit down to think up some

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you feel, what? 

It’s not legal, it’s not advisable, and you shouldn’t do it — but you can earn money that is serious you’re willing to place your body and reputation at stake. You just need to be prepared to commit insurance fraud. But you should know.What before you jump off the curb, there are a few things Is Insurance Fraud?First things first: Did I mention insurance fraud is illegal? You shouldn’t do it, no matter how tempting the payout that is potential. According to the scheme as well as the amount of cash involved, penalties can vary from denied claims and better premiums to felony convictions and prison time that is possible. Sign Up Now

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  • And the definition of insurance fraud is really broad, without realizing it.
  • Insurance so it’s possible to commit it fraud is any deception that is insurance-related for financial gain. Virtually anyone involved in the purchase or sale of insurance can commit it:
  • Insurance consumers, including applicants and policyholders

Insurance agents and brokersFBIInsurance companies and their employees, including claims adjusters, underwriters, and salespeople


Third-party claimants, such as a pedestrian who steps in front of a moving vehicle and then makes a claim on the driver’s insurance

Contractors, health care providers, and other third parties that receive income from insurance companies

Insurance fraud is a business that is big. The

estimates it costs the insurance industry some $40 billion each year, not health insurance fraud that is counting. It adds between $400 and $700 to the family that is average annual insurance premiums.

  • Hard Fraud vs. Soft Fraud 
  • Most cases of insurance fraud fall under 1 of 2 categories: hard fraud and fraud that is soft. The difference that is primary that a person is usually an intentional, planned crime, although the other is oftentimes a crime of opportunity. 
  • Hard Insurance Fraud
  • Hard insurance fraud takes place when a policyholder or claimant that is third-party a claim. Examples of hard insurance fraud include:

Deliberately damaging or destroying property that is insured*)Falsely reporting property as stolen

Engineering a scenario which allows one to file a claim on someone else’s insurance coverage, such as for instance stepping in the front of these car

Otherwise fabricating an insurance coverage claim, such as for instance helping a family member fake their own death to get on the life insurance coverage policy

  • Hard insurance fraud is much more complicated, costly, and better risk for all the perpetrator. It’s therefore not quite as common as one other type that is main of fraud — soft fraud.
  • Soft Insurance Fraud
  • Soft insurance fraud occurs when a policyholder or claimant manipulates an otherwise policy that is valid claim with their own benefit. Common these include:

Intentionally omitting information that is important an insurance application, usually to get a lower premium

Overvaluing insured property to get a higher coverage amount

Exaggerating or misrepresenting the circumstances of a claim, usually to get a higher payout

Common Types of Insurance Fraud

People who work for and with insurance companies understand the inner workings of the insurance industry, so their schemes are often more complicated and can go undetected for long periods. But that doesn’t mean policyholders and claimants can’t commit insurance fraud too. But the type of fraud each combined group commits is significantly diffent. 

Types of Fraud Committed by Policyholders & Claimants

  • Just because someone doesn’t work with an insurance coverage company does mean they can’t n’t commit insurance fraud. Insurance fraud committed by policyholders and claimants falls into three categories, some more serious than others. 
  • Application Fraud
  • Insurance application fraud includes any omission or misrepresentation that occurs during the insurance application process. Classic examples include:

Omitting known health issues from your life insurance application

Intentionally leaving drivers off an auto insurance application

Falsely claiming your vehicle has safety that is built-in

  • Also considered insurance application fraud are fraudulent policy changes that occur following the policy switches into effect. These include removing a driver who still stays in your family out of your auto policy or claiming you installed a true home security system when you didn’t.
  • Claims Fraudcollision insuranceClaims fraud is any misrepresentation or omission that develops through the claims process. Common these include:
  • Filing an insurance claim on property you don’t own — for example, telling your renters insurance carrier that a nonexistent laptop was stolen out of your apartment
  • Adding coverage to pay for a thing that’s already happened to a preexisting policy, then filing a claim under that coverage — for instance, adding
  • on the auto policy covering your already-damaged vehicle to help you hit your insurer up for the cost
  • Not being truthful with insurance company representatives, such as claims adjusters
  • Exaggerating the value of items covered by a property or auto insurance claim

Inaccurate or fraudulent medical billing, such as billing for services not performed — usually done by medical providers and their employees

Changing beneficiary information on a life insurance policy after the insured person’s death

Faking a death to collect a life insurance death benefit

Disaster Fraud

  • Disaster fraud is a narrower type of insurance fraud that occurs around officially declared natural disasters, such as hurricanes, floods, earthquakes, and wildfires. 
  • These large-scale events produce a flurry of property and auto insurance claims that overwhelm insurance companies’ claims departments. In many cases, claims adjusters are unable to visit affected properties or review damage photos as closely as they normally would. They’re more likely to approve fraudulent claims as a result.
  • Examples of disaster fraud include:
  • Homeowners exaggerating the extent of storm or fire damage
  • Homeowners misclassifying damage as disaster-related 

Homeowners concealing or destroying personal property or vehicles and blaming post-disaster looting or vandalism

Contractors inflating the cost of repairs

Contractors billing insurance companies for repair work they never completed

During officially declared disasters, homeowners and contractors can (and do) also defraud the Federal Emergency Management Agency and other U.S. government agencies that distribute aid to disaster victims. Since this aid does qualify as an n’t insurance payout, it is technically not disaster insurance fraud. Nonetheless it’s still illegal.

Types of Fraud Committed by Insurance Agents, Brokers, & Company Employees

Insurance fraud committed by those who work with in accordance with insurance agencies is nearly going to become more serious. Several of their fraud types can affect insurance buyers negatively as well as companies.

Premium Diversion

Premium diversion occurs when authorized insurance sellers like insurance agents and brokers keep a portion of the premiums they collect from customers instead of sending the entire amount to the insurance company.

  • In effect, they’re stealing from both the policyholder and the insurance company. They typically conceal the theft by creating two different versions of a policy: one for the insurance company and one for the policyholder. They may also charge policyholders for bogus add-ons that don’t actually add value to your policy and keep consitently the difference.
  • Unauthorized Sales (Insurance Sales Scams)
  • This form of fraud takes place when a realtor, broker, or company representative sells insurance without authorization. They could:
  • Claim they’re connected to a insurance that is particular when they’re not

Claim to have a license to sell insurance in a particular state when they don’t

Claim that a financial product they’re selling is insurance when it’s not

Represent a fake insurance company that doesn’t sell anything real

Insurance sales scams primarily disadvantage consumers who think they’re buying valid insurance policies when they’re not. But when scammers claim to represent real, legitimate insurance companies, they harm those companies’ reputations by extension.

Fee Churning

This type of fraud occurs between insurance companies and resellers like agents and brokers. Usually, it’s a conspiracy among multiple insurance industry professionals working for a ongoing company put up especially for the scheme. 

Typically, participants repeatedly sell reinsurance — insurance for insurers — on a package of legitimate insurance plans. They collect commissions on every sale, using policy premiums because their commission money box. Eventually, there’s not money that is enough to pay out on legitimate claims and the scheme collapses, potentially taking down the insurance company with it. 

But it can also be simpler. For example, an agent can convince clients to cash their life insurance policy out and change it with another similar policy, sometimes repeatedly, collecting a commission each and every time.


Denying Legitimate Claims

This is a grayer area than insurance sales scams or diversion that is premium. All the time, and those denials are often defensible.

But after all, insurance companies deny seemingly legitimate claims insurance agencies as well as their representatives can deny claims with no reason that is good known as a bad-faith denial.

Penalties for Insurance Fraud


Insurance fraud penalties depend on multiple factors, including the type of fraud and the amount of money involved. Though every state has laws insurance that is defining, precise definitions and penalties vary by location.

That said, many cases of insurance fraud, including ones that are seemingly trivial can be charged as felonies. 

On the consumer side, fines for insurance fraud can range into the thousands or tens of thousands of dollars per infraction. Prison time is also a possibility — up to years that are several according to the state and infraction. First-time offenders generally don’t spend significant levels of amount of time in prison, though.

On the industry side, insurance sales scammers and premium diverters face significant fines and can even be asked to pay restitution (financial compensation) to the people directly afflicted with their activities. Prison time is the possibility on their behalf at the same time. Conspiracies company that is involving, such as fee churning schemes, may generate bigger fines and settlements with state and federal regulators.

How Does Insurance Fraud Affect You?

Insurance fraud is never a crime that is victimless just because it looks like not one person got hurt. It could affect you as a policyholder or policyholder that is would-be directly or indirectly.

Indirect Effects of Insurance Fraud

  • For policyholders, the indirect effects of insurance fraud are primarily financial. The FBI estimates that insurance fraud adds several hundred dollars to the family that is typical insurance fees every year. 
  • Direct results of Insurance Fraud( people that are*)Many through life without ever being directly affected by insurance fraud. That’s a thing that is good insurance fraud costs a large amount more for people directly afflicted by it.
  • Depending from the circumstances, insurance fraud that directly targets you’ll be able to bring about:
  • A worthless policy or coverage you can’t make a claim on

Direct financial losses through diverted premiums

Denial of the best claim

Higher premiums on the best policy because of a fraudulent third-party claim

Insurance Fraud FAQs

  • Like insurance itself, insurance fraud is an elaborate topic. About it, you’re sure to have questions like these.
  • Who as you learn more Commits Insurance Fraud?
  • Virtually anyone can commit insurance fraud. Potential perpetrators include:
  • Insurance applicants — consumers and business owners

Insurance policyholders

People filing insurance claims, including policyholders and third-party claimants

People who sell insurance, including insurance agents, brokers, and company salespeople

Other insurance company employees, including claims adjusters

How Do I Report a Suspected Insurance Fraud Scheme?National Insurance Crime BureauIt depends on the situation.

If you believe you’re being targeted by an unscrupulous or insurance that is unlicensed or broker, first report it to your insurance carrier they promise to represent. Most insurance agencies have an ongoing process for reporting suspected fraud.

Likewise, It to your insurer if you believe a third party is making a fraudulent claim on your policy, report. 

You don’t have to stop there — and in many fraud cases, you shouldn’t. Once you’ve reported the issue to the insurance company, file another report with the

, the insurance that is primary bureau in america. 

You may also report insurance fraud to a state insurance commission or department of insurance as well as other agencies that regulate insurance agencies or enforce insurance law. As an example, it.

What’s if you suspect that a health insurance company doing business with your state’s health insurance exchange is breaking the law, file a complaint with the state agency that oversees the Most Common Type of Insurance Fraud?

Of the two broad categories of insurance fraud, soft fraud is more common than hard fraud. Among the various types of insurance, auto insurance fraud is probably the most common, though lots of insurance fraud goes unreported.

Generally, Opportunistic and straightforward types of insurance fraud tend to be more common than complicated schemes and rackets. It’s far more common for an automobile insurance policyholder to underestimate exactly how much they drive or keep a driver that is problematic the policy than to torch their own car and claim a vandal did it.

How Do I Appeal if My Legitimate Claim Is Called a False Claim?


It depends on the type of claim filing that is you’re your insurance company’s procedures for appeals. However in general, you should submit documentation that is additional evidence to address the specific reasons the insurer denied your claim. (you can hire a public claims adjuster or insurance attorney*)If you don’t get anywhere on your own. In the event that you don’t win, though you may have to pay for hard costs like court-filing or document fees upfront.death and taxesTo if you win, your claim payout covers their contingency fees, so you don’t pay a lot learn more about the nuances of appealing a insurance that is denied, read our guides to:

imagine if My insurance carrier or insurance professional Is tangled up in Insurance Fraud?

Report the suspected fraud to your insurance company’s fraud reporting hotline if this has one. Even though you accomplish that, file a complaint that is separate the National Insurance Crime Bureau and your state insurance regulator to ensure some measure of external accountability.(*)Final Word(*)Like (*), insurance fraud is a known fact of life. It’s not going away. All that you may do to guard yourself is discover ways to spot suspected fraud, know where and when to report your suspicions, and get away from insurance “professionals” who don’t appear to have your very best interests at heart.(*)Oh, and prevent fraud that is perpetrating. You probably don’t plan to step in front of a car that is moving soon, but think hard before omitting anything out of your next insurance application. That’s technically fraud too.(*)