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:

Dianne submitted a claim for disability insurance benefits, and she was paid $4,862.38 in disability proceeds. During the disability claim investigation, surveillance, and an interview with Dianne, the insurance company found out that she had been running her own in-home day care. Dianne reimbursed the insurance company for all of the proceeds that she had been paid.

Answer 1:

Question 2:

Jenny filed a claim for disability. The Independence Life & Health Insurance Company said that her condition does not meet the policy definition of 'disability'. Jenny's claim was denied and then she filed a complaint with the Missouri Department of Insurance.

Answer 2:

Question 3:

Tammy filed a claim with her auto insurance company for hail damage two moths ago. The auto insurance company asked for proof of loss and specifically asked her to take pictures and mail them in. Tammy refused to take pictures because she felt that a claim adjuster should view her car and write her a check on the spot without questions asked. Her claim was denied due to lack of cooperation.

Answer 3:

Question 4:

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 4:

Question 5:

Kevin fell on Gloria's front porch on 2/15/03 due to ice and snow, and injured his right shoulder. When asked for proof of his loss, Kevin gave the insurance company permission to ask his doctor for a copy of his medical records. After a review of Kevin's medical records the company found a note that indicated Kevin also fell in January of 1999. The March 2003 doctor's records indicate that the current injury was fully caused by the February 2003 fall. The insurance company is asking Kevin to see one of their doctors to verify what his doctor has determined. The insurance company's doctor may or may not agree with Kevin's doctor.

Answer 5: