Insurance Fraud Questions

Insurance Fraud Quiz

What is Fraud?
According to Missouri Statute §375.991 RSMo., a person commits a "fraudulent insurance act" if he or she knowingly makes a statement or written document for a claim or insurance application which that person knows to contain material false information or conceals information concerning a material fact.
What is a policy dispute?
A policy dispute can be many things. You may have a policy dispute if it is questionable that you had coverage at the time of an accident. A policy dispute could be a disagreement about how an insurance company handles your claim (Mo. Reg. 20 CSR 100). Or, a policy dispute could be if your claim is denied because of a misrepresentation that is not material to the loss covered on the policy (§376.580 RSMo).
This quiz is developed for example purposes only. The questions and answers in this quiz are not to be construed as an opinion or position taken by the Missouri Department of Insurance. If you believe that you have a claim that should be paid, you may wish to ask the Consumer Affairs Section of the Missouri Department of Insurance for assistance by calling 1-800-726-7390 or check us out on line.

Question 1:

Mr. Grantham submitted a claim for furniture items that were stolen from his apartment. He had sold the same property that he claimed were stolen. Mr. Grantham did not pursue the claim after the Big River Insurance Company advised him of their knowledge of his sale of the property. Claim Closed.

Answer 1:

Question 2:

The insured, Alex, was three months late on his monthly car payment when his car was stolen. Alex told the lien holder, River Bend Savings & Loan that he was out of town when the theft occurred, but later he told the claim adjuster for the insurance company that he was working at his second job at that time. No broken glass was found at the insured's apartment where the vehicle was parked. Alex's car was recovered in a burnt condition. The door locks did not appear damaged, the radio was in the vehicle, the wheels and tires were still attached, and no other parts appeared to be missing.

Answer 2:

Question 3:

Jake Donaldson alleges that he cut his gum on a piece of glass, which was found in his grilled chicken sandwich on April 23. After six months of requests, Protection Casualty Company has not received medical records to substantiate Mr. Donaldson's claim. Prior to leaving the restaurant on April 23, one of the members of the group with Jake at the time said to the shift manager, "don't worry, he does this all the time to try and get free food".

Answer 3:

Question 4:

Cathy Southfield goes to Dr. Hendrickson for Chiropractic treatments every other week. PeopleSmart HMO conducted a standard review of Cathy's medical records after every third visit. Upon review, PeopleSmart HMO investigators found a note that Dr. Hendrickson wrote. The note is from Dr. Hendrickson and tells the nurse to change the description and diagnosis of Cathy's condition every 180 days so that she can keep getting treatment. Cathy's plan will only pay for 26 visits, per condition, each year.

Answer 4:

Question 5:

Janet completed an application for credit life insurance for the loan on her new car. She was asked if she had any pre-existing health conditions for heart attacks. She said no. Janet died from a heart attack 6 months later. The autopsy indicated that Janet had a small heart attack one year ago, but may have thought it was indigestion or heart burn at that time. If she would have seen the doctor for her problem a year ago, the doctor might have diagnosed her with heart disease.

Answer 5: