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Pennsylvania Insurance Fraud Laws

Overview of Pennsylvania Insurance Fraud Laws

In Pennsylvania, a person is guilty of insurance fraud if he or she acts in one of several ways specified in the statute "with the intent to defraud" another person, whether it be an agency, insurer, or self-insured individual. Specifically, a person commits insurance fraud when he or she:

  • Knowingly and with the intent to defraud a state or local government agency files, presents, or causes to be filed with the government agency a document that contains false, incomplete or misleading information concerning any fact or thing material to the agency's determination in approving or disapproving any motor vehicle insurance action which is required or filed in response to an agency's request.
  • Knowingly and with the intent to defraud any insurer or self-insured, presents or causes to be presented to any insurer or self-insured any statement forming a part of, or in support of, a claim that contains any false, incomplete or misleading information concerning any fact or thing material to the claim.
  • Knowingly and with the intent to defraud any insurer or self-insured, assists, abets, solicits or conspires with another person to prepare or make any statement that is intended to be presented to any insurer or self-insured in connection with, or in support of, a claim that contains any false, incomplete or misleading information concerning any fact or thing material to the claim, including information which documents or supports an amount claimed in excess of the actual loss sustained by the claimant.
  • Knowingly engages in unlicensed agent, broker or unauthorized-insurer activity with the intent to defraud an insurer, a self-insured or the public.
  • Knowingly benefits, directly or indirectly, from the proceeds derived from an insurance fraud violation due to the assistance, conspiracy or urging of any person.
  • Is the owner, administrator or employee of any health care facility and knowingly allows the use of such facility by any person in furtherance of a scheme or conspiracy to violate the insurance fraud provisions.
  • Borrows or uses another person's financial responsibility or other insurance identification card, or permits his or her card to be used by another, knowingly and with intent to present a fraudulent claim to an insurer.
  • If, for financial gain, he or she directly or indirectly solicits any person to engage, employ or retain himself, herself or any other person to manage, adjust or prosecute any claim or cause of action against any person for damages for negligence; or directly or indirectly solicits other persons to bring causes of action to recover damages for personal injuries or death (excluding conduct otherwise permitted by law or by rule of the Supreme Court).

The insurance fraud statute also prohibits lawyers and health care providers from compensating another person in exchange for the person's recommendation or securing of the lawyer or health care provider's services. Nor may a person "knowingly and with intent to defraud any insurance company, self-insured or other person" file an application for insurance containing any false information, or conceal information concerning any fact material to the application. The statute classifies these particular offenses as misdemeanors of the first degree.

Where a defendant presents a claim to an insurer containing false, incomplete or misleading information, his or her fraudulent intent may be inferred from the giving of false answers under circumstances such that the defendant must have been aware of their falsity.

Defenses to Insurance Fraud Charges

  • Lack of knowledge or intent to defraud
  • Duress
  • Entrapment
  • Insanity

Penalties and Sentences

With the exception of those offenses identified as misdemeanors of the first degree, all other insurance fraud offenses are felonies of the third degree. In Pennsylvania, such felonies are normally punishable by a term of up to 7 years in prison, and/or a fine of up to $15,000. A conviction for a misdemeanor of the first degree, on the other hand, is generally subject to a sentence of up to 5 years in prison, and/or a fine of up to $10,000.

However, under the Pennsylvania insurance fraud statute, if a defendant is found, pursuant to a claim initiated by a prosecuting authority, to have violated the statute, he or she will instead be subject to civil penalties of up to $5,000 for the first violation, $10,000 for the second violation, and $15,000 for each subsequent violation. Such penalty shall be paid to the prosecuting authority, which may also be awarded court costs and reasonable attorney fees. Finally, the court may also sentence a person convicted of insurance fraud to make restitution.

In addition, the statute also permits insurers damaged as a result of insurance fraud to sue the defendant in a civil action to recover compensatory damages, including reasonable investigation expenses, costs and attorney fees. If the court determines that the defendant has engaged in a "pattern" of insurance fraud, the insurer may be entitled to recover treble damages.

Pennsylvania Insurance Fraud Statute

Insurance Fraud

Pennsylvania Statutes Title 18, Chapter 41, Section 4117

Note: State laws are constantly changing -- please contact an attorney or conduct your own legal research to verify the state law(s) you are researching.

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