More than one kind of money is at stake
In New York, insurance fraud is a crime graded largely by the value involved, and a court can impose a fine along with other parts of a sentence, including restitution to the insurer. Separately, an insurer or regulator may seek civil penalties, demand repayment of benefits, or rescind a policy. The New York Department of Financial Services investigates insurance fraud, and insurers are generally required to report suspected fraud. A claim can therefore lead to a criminal investigation, a civil fight over payment, and policy consequences all at once, each moving on its own schedule.
What the insurer may already have
Special investigation units often review recorded statements, claim forms, medical or repair records, social media posts, and data from other claims databases before a person realizes there is a problem. If you have been asked to give an examination under oath or a recorded statement, your policy may require cooperation, but how you answer can affect both coverage and potential charges. Gather your policy, claim correspondence, and documents supporting the loss, and avoid altering or supplementing submissions without advice. Do not contact witnesses or providers to align stories.
How we assess the exposure
At the outset we try to determine whether the matter is still a coverage dispute or has become a fraud referral, and whether law enforcement is involved. We review the claim file, the policy language, and what was actually said or submitted, since misunderstandings and errors are different from knowing falsehoods. Where charges are possible, we discuss how restitution, fines, and other penalties might be addressed and what a resolution could mean for your licenses, employment, or immigration status.
