Episode 5: Individual and Business Civil Insurance Fraud Claims

Firm partners Evan Schwartz and Matt Conroy discuss Civil Insurance Fraud and understanding the many issues that can arise when dealing with these claims and litigation, particularly the criminal liability proceedings that can follow.

Podcast Show Notes

In this episode of the Insurance Lawyer, host Evan Schwartz discusses Civil Insurance Fraud with firm partner, Matt Conroy. Fraud can occur in many different types of insurance, such as home insurance, disability insurance, auto insurance or life insurance.

When defending in a civil insurance fraud claim by a carrier, you must keep in mind that there is potential for implications of criminal proceedings arising as a result of those claims or accusations. A practitioner needs to understand where the alleged fraudulent activity comes from and what type of fraud it is, the size of the claim, what type of client will be prosecuted, and whether it is a conspiracy or a truly criminal act. If the claim contains a criminal act, you will want to get a second lawyer – one who is a criminal lawyer – to consult with.

It is not necessary to bring in a criminal lawyer when there is a civil dispute between an insurance company and a policyholder. Typically, the insurance company is trying to avoid its obligations because something isn’t necessarily true on the application. There will be civil issues of whether it was an intentional omission, whether it was something that is material, or whether the client knew it was false at the time it was made. However, it is necessary to bring in a criminal lawyer when your client has staged a policy, or a job disability if it is in terms of disability insurance, in order to illegally receive benefits. This is only necessary if the insurance company relied on false information and then were induced to pay.

There are other forms of insurance that fraud can be common among, such as Worker’s Comp, No-Fault, Medicare, and Medicaid. In these examples, civil actions are taken by divisions of the government for civil restitution, which ultimately leads to criminal prosecution by the federal or state government.

All fraud cases involve the claimant misstating some material fact to the insurance company, such as proof of loss, or the items or services contained on a medical bill, or even if the provider of service is eligible for reimbursement.

When your client appears to have made intentional misrepresentations of information, which resulted in someone losing money, you must consider how you will represent to the court. Whether to advise your client to either advance that position, contradict that position, or change his position. This might raise some ethical issues, this could raise criminal issues for the client and yourself.


Fraud is a tricky area of the law, and there are many elements that need to be proven, in order to prove that one side or another actually engaged in a fraudulent act. Some cases may require a second lawyer based in criminal law, in order to receive more assistance if the client has staged a policy to illegally obtain benefits.