Where these cases start
Insurers have special investigations units that review claims they consider suspicious, and in New York they are required to report suspected fraud to the state's financial services regulator. Those referrals, along with data analysis across many claims, feed criminal investigations by state investigators, district attorneys, and sometimes federal prosecutors. Cases range from an inflated property claim to organized no-fault schemes involving clinics and recruited drivers. Misstatements on an insurance application, such as where a car is garaged, can also become the basis of a charge. New York grades insurance fraud largely by the amount involved, and related charges such as larceny or falsifying business records often appear alongside it.
Before you sit for an interview or examination
An examination under oath is a contractual right many insurers have when investigating a claim, but what you say there is recorded and can be shared with prosecutors. You can bring counsel, and in this situation you usually should. Keep copies of everything you submitted with the claim, along with receipts, repair estimates, medical records, and photographs. Do not revise, replace, or backdate documents you already submitted. If someone else prepared your claim, such as a public adjuster, a clinic, or an attorney, keep your communications with them, since their role may be part of the investigation.
Mapping out the case
We look first at whether you are facing a claim denial, a civil suit by the insurer, a criminal investigation, or a combination, because each moves on its own timeline. Insurers sometimes sue to recover payments while prosecutors decide whether to charge. We review what was submitted, who prepared it, and what you knew at the time. Whether there was an intent to deceive, rather than a mistake or someone else's exaggeration, often shapes the case. If your policy has been canceled or a payment withheld, we also look at whether the insurer met its own obligations. For licensed professionals and non-citizens, the consequences of any disposition are reviewed early.
