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 The effect of t his amendment will be that all insurers, including workers comp carriers must report fraud to the Fraud Unit; this will allow TDI to get accurate data with regards to the amount and types of fraud suspected by the industry. Impact to the Fraud Unit will be determined as carriers begin to comply with the statute.The effect of t his amendment will be that all insurers, including workers comp carriers must report fraud to the Fraud Unit; this will allow TDI to get accurate data with regards to the amount and types of fraud suspected by the industry. Impact to the Fraud Unit will be determined as carriers begin to comply with the statute.

4. Types of Complaints Investigated by the Fraud Unit Claim Fraud – committed against a company. Worker’s 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.

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 Cont’d 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 TDI’s 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/fraud/frsiufrrpt.html Faster More comprehensive Easy data entry Secure transmission