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:

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 1:

Question 2:

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 2:

Question 3:

Mr. Harris purchases insurance coverage for his car at 10:00 A.M. on September 1 from KC Auto Insurance Company. He stated to his agent and on his application that there is no damage to the car and no prior accidents. Mr. Harris called the insurance company at 10:30 A.M. and said that he was in an accident at 10:15 A.M. while leaving the parking lot of the insurance agent. The check that Mr. Harris wrote for the insurance coverage unfortunately bounced and was sent back to the company as an 'insufficient funds' transaction.

Answer 3:

Question 4:

Mr. Townsend submitted a claim for furniture items that were stolen from his apartment. He intended to sell them at his garage sale in a week. He told all of his friends about his garage sale and invited them to see his furniture two weeks before the garage sale. From the information available to the investigators, it appears that Mr. Townsend's apartment was broken into and that he may be the victim of random burglars.

Answer 4:

Question 5:

Mrs. Court took out a life insurance policy on Jim, 20 years ago, when he was 3. Jim has a condition that leaves him unable to independently take care of himself as an adult. Jim lives with his parents who have P.O.A. (Power Of Attorney) over his affairs. Mrs. Court called the insurance company to change his beneficiary to Jim's Estate. The insurance company refused to process the paperwork until Mrs. Court furnished a copy of the POA.

Answer 5: