Texas Department of Insurance Fraud Unit

1
Texas Department of Insurance Fraud Unit

• REPORTING SUSPECTED
• INSURANCE FRAUD
• Dennis Pompa, Associate Commissioner

2
Texas Department of Insurance Fraud Unit

• Insurance Fraud Reporting Requirements
• Types of Complaints Investigated
• Investigation Process
• Elements of a Comprehensive Fraud Report
• Fraud Reporting Tips

3
Reporting Requirements - Texas Ins Code 701.051

• A person must report fraud not later than the
  30th day after he makes a determination or
  reasonably suspects that a fraudulent insurance
  act has been or is about to be committed in this
  state
• A person shall make the report of suspected fraud
  in writing to the insurance fraud unit
• The report shall be made in a format prescribed
  by the Fraud Unit or NAIC

4
Types of Complaints Investigated by the Fraud
Unit

• Claim Fraud committed against a company.
• Workers Comp claimant, provider or producer
  fraud.
• Agent Fraud / Adjuster Fraud committed against
  the public or a company.
• Internal Fraud committed against a company, the
  public or the government.
• Unauthorized fraudulent insurance plans.

5
(No Transcript)
6
Elements of a Comprehensive Fraud Report

• Who was involved in the fraud?
• Provide detailed identifying information on all
  persons involved.
• Vehicles or personal property details.
• When did the suspected fraud occur?
• Where did the fraud occur?
• When was the claim reported?
• Explain your efforts to contact parties involved
  in fraud.

7
Elements of a Comprehensive Fraud Report Contd

• Tell us if the claim been paid, if so include
  amount was the claim denied or pending?
• A synopsis of why you suspect the claim to be
  fraudulent.
• What documents/evidence do you have to support
  your allegations?
• Your contact information

8
Tips When submitting reports to TDIs Fraud Unit

• Acronyms or abbreviations provide a legend that
  defines the terms
• Checks provide a front and back side copy of
  the check
• Provide complete legible copies of all documents
  submitted to the Unit
• Provide color photographs when available
• Provide dates, times and personal identifiers of
  all individuals present during an interview or
  statement

9
Tips When submitting reports

• Provide a copy of the policy, most importantly a
  copy of the Declaration page
• Narrative reports be detailed, explain
  everything, state how the claim was made, i.e.,
  telephone, mail including where the claim was
  made

10
Referrals, Indictments Convictions
11
ONLINE REPORTING OF FRAUDwww.tdi.state.tx.us/fra
ud/frsiufrrpt.html

• Faster
• More comprehensive
• Easy data entry
• Secure transmission