“Insurance policy” means a written instrument which is provided the terms of any certificate of insurance, binder of coverage, contract of insurance, benefit plan, nonprofit hospital service plan, motor club service plan, surety bond, cash bond, or any other alternative to insurance. The term includes any instrument authorized to be regulated by the Texas Department of Insurance.
– “Statement” means an oral or written communication or a record or documented representation of fact made to an insurer. The term includes computer-generated information.
– “Value of the claim” means the total dollar amount of a claim for payment under an insurance policy.
MATERIALITY. A statement is material if the statement could have affected:
– the eligibility for coverage or amount of the payment on a claim for payment under an insurance policy; or
– the decision of an insurer on whether to issue an insurance policy.
INSURANCE FRAUD.
A person commits an offense if, with intent to defraud or deceive an insurer, the person, in support of a claim for payment under an insurance policy prepares or causes to be prepared a statement that:
– the person knows contains false or misleading material information; and is presented to an insurer; or presents or causes to be presented to an insurer a statement that the person knows contains false or misleading material information.
A person commits an offense if the person, with intent to defraud or deceive an insurer and in support of an application for an insurance policy prepares or causes to be prepared a statement that:
– the person knows contains false or misleading material information; and
– is presented to an insurer; or
– presents or causes to be presented to an insurer a statement that the person knows contains false or misleading material information.
A person commits an offense if, with intent to defraud or deceive an insurer, the person solicits, offers, pays, or receives a benefit in connection with the furnishing of goods or services for which a claim for payment is submitted under an insurance policy.
An offense is:
– a Class C misdemeanor if the value of the claim is less than $100;
– a Class B misdemeanor if the value of the claim is $100 or more but less than $750;
– a Class A misdemeanor if the value of the claim is $750 or more but less than $2,500;
– a state jail felony if the value of the claim is $2,500 or more but less than $30,000;
– a felony of the third degree if the value of the claim is $30,000 or more but less than $150,000;
– a felony of the second degree if the value of the claim is $150,000 or more but less than $300,000; or
A felony of the first degree if:
– the value of the claim is $300,000 or more; or
– an act committed in connection with the commission of the offense places a person at risk of death or serious bodily injury.
The court shall order a defendant convicted of an offense under this section to pay restitution, including court costs and attorney’s fees, to an affected insurer.
If conduct that constitutes an offense also constitutes an offense under any other law, the actor may be prosecuted under this section, the other law, or both.
– If the actor proves by a preponderance of the evidence that a portion of the claim for payment under an insurance policy resulted from a valid loss, injury, expense, or service covered by the policy, the value of the claim is equal to the difference between the total claim amount and the amount of the valid portion of the claim.
If it is shown on the trial of an offense under this section that the actor submitted a bill for goods or services in support of a claim for payment under an insurance policy to the insurer issuing the policy, a rebuttable presumption exists that the actor caused the claim for payment to be prepared or presented.
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