Haris Ashley
Insurance fraud is a costly and serious issue, and it is important to know how to report it. Insurance fraud occurs when an insurance company, agent, adjuster, or consumer commits deliberate deception to obtain an illegitimate gain. This can take many forms, including padding claims, staging incidents, giving a false address, or medical providers falsifying diagnoses. It is illegal to assist or conspire with someone to commit insurance fraud. If you suspect insurance fraud, you can report it to the relevant authorities, such as the Criminal Investigations Division or the Fraud Division of the Department of Insurance, depending on who is committing the fraud. Licensed insurance agents and carriers are legally required to report suspected fraud. The public can also report suspected insurance fraud through online portals or by completing a Consumer Insurance Fraud Reporting Form and mailing it to the relevant authority.
| Characteristics | Values |
|---|---|
| Location | Georgia, Pennsylvania, California |
| Website | Office of the Commissioner of Insurance and Safety Fire, Insurance Department of the Commonwealth of Pennsylvania, California Department of Insurance |
| Who should report | Licensed insurance agent or carrier, consumer/industry representative |
| What to report | Suspected insurance fraud, violation of insurance law, insurance fraud committed by an agent or broker, fraud committed by an employee, employer, medical provider, legal provider, or someone committing insurance fraud |
| How to report | Online portal, fax, mail, phone, Consumer Insurance Fraud Reporting Form |
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What You'll Learn
- Report to the Criminal Investigations Division of the Department of Insurance
- Contact the Consumer Services Division if you disagree with the Department's response
- Report fraud by an agent or broker to the Investigation Division
- Report fraud by an employee, medical provider, or legal provider to the Fraud Division
- Complete the Consumer Insurance Fraud Reporting Form and mail it to the California Department of Insurance
Report to the Criminal Investigations Division of the Department of Insurance
If you suspect illegal insurance activity, you may need to report it to the Criminal Investigations Division of the Department of Insurance. In the state of California, the Fraud Division of the California Department of Insurance is the largest law enforcement unit within the Enforcement Branch. It is made up of over 266 staff members serving in nine regional offices across the state. The Fraud Division investigates crimes related to section 550 of the Penal Code, the California Insurance Code, and other related crimes such as conspiracy, human trafficking, grand theft, and automobile theft.
In North Carolina, the Department of Insurance was granted specific Law Enforcement Authority in 1945, and two Law Enforcement units were created. The Investigations Division was tasked with handling insurance fraud, insurance agent embezzlement, and other insurance-related financial crimes. The Special Services Division was given regulatory authority over the bail bond industry, motor club carriers, collection agencies, and the premium finance industry. The North Carolina Department of Insurance leads national efforts in combating insurance fraud.
Licensed insurance agents or carriers are legally required to report suspected fraud to the Criminal Investigations Division of the Department of Insurance. Reports can be made through an online portal, by fax, mail, or phone. To ensure a thorough investigation, you should be prepared to provide your contact information and any relevant documentation to support your allegation.
If you are unsure whether a particular activity constitutes illegal insurance behaviour, you can refer to the insurance code of your state or country. Additionally, if you are not satisfied with the response from the Department of Insurance, you can contact the Consumer Services Division and ask to speak with a supervisor.
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Contact the Consumer Services Division if you disagree with the Department's response
If you disagree with the Department's response to your complaint, there are a few steps you can take to further address your concerns. It is important to note that you should keep records of all communications and correspondence with the insurance company during the complaint process.
Firstly, contact your insurance company and attempt to resolve the issue. State your complaint clearly and ask what the next steps are to submit your dispute formally. This may involve writing a formal letter of complaint, filing specific forms, or providing supporting documentation. Keep meticulous records of all communications, including names, dates, phone numbers, and summaries of conversations. Retain copies of all emails sent and received, and gather and send all required documentation to the relevant addresses.
If you are still dissatisfied with the response, you can then contact the Consumer Services Division and ask to speak with a supervisor. The Consumer Services Division is the investigative arm of the OCI (Office of the Commissioner of Insurance and Safety Fire), and they are responsible for ensuring fair and equitable dealings between insurers, agents, and policyholders. They may be able to help resolve your issue.
When contacting the Consumer Services Division, provide a written rebuttal along with any additional documentation to your assigned Complaints Analyst. The analyst will forward your rebuttal to the agency or company you initially complained about and request a detailed written response.
If you need assistance finding an attorney at any stage of the process, you can contact the State Bar of Georgia Lawyer Referral Information Service.
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Report fraud by an agent or broker to the Investigation Division
If you suspect that an insurance agent or broker is committing fraud, you can report it to the Investigation Division of the California Department of Insurance. The Department has set up a method for the general public to report cases of suspected insurance fraud. As per California Insurance Code section 1879.5, no person shall be subject to civil liability for filing a good faith report of suspected insurance fraud.
You can report the fraud by filling out the Consumer Insurance Fraud Reporting Form and mailing it to the following address:
California Department of Insurance
Enforcement Branch Headquarters
Intake Unit
2400 Del Paso Road
Suite 250
Sacramento, CA 95834
Alternatively, you can report the fraud online through the new online portal provided by the Criminal Investigations Division of the Department of Insurance. To ensure that your report can be effectively investigated, you should be prepared to provide your contact information (name, address, telephone number, and email address) and any documentation that supports your allegation.
If you or someone you know has been a victim of a scam or fraud scheme, you can also report it to ic3.gov, the FBI's Internet Crime Complaint Center (IC3). The FBI provides resources to help people protect themselves from scammers and guidance on what to do if they become a victim.
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Report fraud by an employee, medical provider, or legal provider to the Fraud Division
If you suspect insurance fraud and want to report it, the relevant department depends on who is committing the fraud. If fraud is being committed by an employee, employer, medical provider, or legal provider, you should contact the Fraud Division.
In California, the Department of Insurance has a process for members of the public to report suspected insurance fraud. This can be done by mailing a completed Consumer Insurance Fraud Reporting Form to the Enforcement Branch Headquarters Office. The form and mailing address can be found on the California Department of Insurance website. As per California Insurance Code section 1879.5, no person shall be subject to civil liability for filing a good faith report of suspected insurance fraud to the Department of Insurance.
In Georgia, reports of suspected fraud can be made through the Office of the Commissioner of Insurance and Safety Fire's new online portal. Alternatively, reports can be made by fax, mail, or phone. The Criminal Investigations Division of the Department of Insurance should be contacted if you are a licensed insurance agent or carrier reporting suspected fraud.
If you are a provider and suspect that your identity has been stolen, you can get information on how CMS can help through the Victimized Provider Project.
The Office of Inspector General (OIG) Hotline Operations also accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in the U.S. Department of Health and Human Services’ programs. You can also report fraud about Medicare, Medicaid, and other HHS programs to the HHS-OIG.
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Complete the Consumer Insurance Fraud Reporting Form and mail it to the California Department of Insurance
If you suspect insurance fraud, you can report it. Insurance fraud occurs when an insurance company, agent, adjuster, or consumer commits a deliberate deception in order to make an illegitimate gain. This can occur during the process of buying, using, selling, or underwriting insurance. Examples of insurance fraud include submitting claims for injuries or damages that never happened, staging incidents, and "padding" or inflating actual claims to get a higher payment.
If you want to report insurance fraud in California, you can do so by completing the Consumer Insurance Fraud Reporting Form and mailing it to the California Department of Insurance. The form should be mailed to the following address:
California Department of Insurance
Enforcement Branch Headquarters Intake Unit
2400 Del Paso Road
Suite 250
Sacramento, CA 95834
Alternatively, you can deliver the form in person to the Enforcement Branch Headquarters Office at the same address. It is important to note that, as noted in California Insurance Code section 1879.5, no person shall be subject to civil liability for filing a good faith report of suspected insurance fraud to the Department of Insurance.
If you are a licensed insurance agent or carrier, you may be legally required to report suspected fraud to the relevant authorities. In some jurisdictions, reports can be made through an online portal, by fax, mail, or phone. When reporting suspected fraud, it is helpful to provide as much information as possible, including your contact information and any documentation that supports your allegation. Once the investigation is complete, you will typically receive a formal letter confirming its conclusion.
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Frequently asked questions
You can report suspected insurance fraud to the Criminal Investigations Division of the Department of Insurance. Reports can be made through their online portal, or by fax, mail or phone.
The Insurance Department of the Commonwealth of Pennsylvania has a Help Centre where you can report insurance fraud.
You can report suspected insurance fraud to the California Department of Insurance. Complete the Consumer Insurance Fraud Reporting Form and mail it to the Enforcement Branch Headquarters Intake Unit.
Insurance fraud occurs when an insurance company, agent, adjuster or consumer commits a deliberate deception to obtain illegitimate gains. This can include submitting claims for injuries or damages that never happened, or "padding" claims to get a higher payment.
If you are not satisfied with the response to your complaint, you can contact the Consumer Services Division and ask to speak with a Supervisor.
