PENAL CODE
CHAPTER 35. INSURANCE FRAUD
§ 35.01. DEFINITIONS. In this chapter:
(1) "Health care goods" means a tangible product,
device, medicine, or other object provided in conjunction with a
health care service.
(2) "Health care provider" means a person who renders
health care services or an agent or employee of an organization that
renders or provides a facility and means to render health care
services. The term includes a physician, surgeon, person who may be
selected by an insured or a beneficiary under Article 21.52,
Insurance Code, and person defined as a provider of health care
under Section 152.003, Occupations Code.
(3) "Health care service" means a service that is
intended to improve or maintain the physical or mental condition of
an individual and that is rendered, directed, or supervised by a
health care provider.
(4) "Insurer" means a person who engages in the
business of insurance in this state, including:
(A) an insurer that is not authorized to do
business in this state;
(B) a health maintenance organization;
(C) a group hospital service corporation
regulated under Chapter 842, Insurance Code; and
(D) any person who self-insures and provides
health care benefits to the person's employees.
(5) "Statement" means an oral or written communication
or a record or documented representation of fact evidencing a loss,
injury, or expense. The term includes computer-generated
information.
Added by Acts 1995, 74th Leg., ch. 621, § 1, eff. Sept. 1, 1995.
Amended by Acts 2001, 77th Leg., ch. 1420, § 14.830, eff. Sept.
1, 2001; Acts 2003, 78th Leg., ch. 1276, § 10A.541, eff. Sept.
1, 2003.
§ 35.02. INSURANCE FRAUD. (a) A person commits an
offense if, with intent to defraud or deceive an insurer, the person
causes to be prepared or presents to an insurer in support of a
claim for payment under a health or property and casualty insurance
policy a statement that the person knows contains false or
misleading information concerning a matter that is material to the
claim, and the matter affects a person's right to a payment or the
amount of payment to which a person is entitled.
(b) 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 health care
goods or services for which a claim for payment is submitted under a
health or property and casualty insurance policy.
(c) For purposes of Subsection (a), information concerning
a matter that is material to a claim for payment under an insurance
policy includes information concerning:
(1) whether health care goods or services were
provided;
(2) whether health care goods or services were
medically necessary under professionally accepted standards;
(3) the nature of the health care goods or services
provided;
(4) the date on which health care goods or services
were provided;
(5) the medical record of goods or services provided;
(6) the condition treated or diagnosis made;
(7) the identity and applicable license of the
provider or the recipient of health care goods or services;
(8) whether property was damaged or lost in the manner
and under the circumstances described in a statement related to a
claim for insurance payment; or
(9) whether any other claim for insurance payment has
been communicated to any other insurer concerning property damage
or loss to the same property.
(d) An offense under this section is:
(1) a Class C misdemeanor if the value of the claim is
less than $20;
(2) a Class B misdemeanor if the value of the claim is
$20 or more but less than $500;
(3) a Class A misdemeanor if the value of the claim is
$500 or more but less than $1,500;
(4) a state jail felony if the value of the claim is
$1,500 or more but less than $20,000;
(5) a felony of the third degree if the value of the
claim is $20,000 or more but less than $100,000;
(6) a felony of the second degree if the value of the
claim is $100,000 or more but less than $200,000; or
(7) a felony of the first degree if:
(A) the value of the claim is $200,000 or more;
or
(B) the value of the claim is less than $200,000
and the commission of the offense placed a person at risk of death
or serious bodily injury.
(e) 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.
Added by Acts 1995, 74th Leg., ch. 621, § 1, eff. Sept. 1, 1995.
Amended by Acts 2003, 78th Leg., ch. 605, § 1, eff. Sept. 1,
2003.
§ 35.03. AGGREGATION AND MULTIPLE OFFENSES. (a) When
separate claims in violation of this chapter are communicated to an
insurer or group of insurers pursuant to one scheme or continuing
course of conduct, the conduct may be considered as one offense and
the value of the claims aggregated in determining the
classification of the offense. If claims are aggregated under this
subsection, Subsection (b) shall not apply.
(b) When three or more separate claims in violation of this
chapter are communicated to an insurer or group of insurers
pursuant to one scheme or continuing course of conduct, the conduct
may be considered as one offense, and the classification of the
offense shall be one category higher than the most serious single
offense proven from the separate claims, except that if the most
serious offense is a felony of the first degree, the offense is a
felony of the first degree. This subsection shall not be applied if
claims are aggregated under Subsection (a).
Added by Acts 1995, 74th Leg., ch. 621, § 1, eff. Sept. 1, 1995.
§ 35.04. JURISDICTION OF ATTORNEY GENERAL. (a) The
attorney general may offer to an attorney representing the state in
the prosecution of an offense under Section 35.02 the
investigative, technical, and litigation assistance of the
attorney general's office.
(b) The attorney general may prosecute or assist in the
prosecution of an offense under Section 35.02 on the request of the
attorney representing the state described by Subsection (a).
Added by Acts 1995, 74th Leg., ch. 621, § 1, eff. Sept. 1, 1995.
