2014 Delaware Code
Title 11 - Crimes and Criminal Procedure
CHAPTER 5. SPECIFIC OFFENSES
Subchapter III Offenses Involving Property
§ 913. Insurance fraud; class G felony

(a) A person is guilty of insurance fraud when, with the intent to injure, defraud or deceive any insurer the person:

(1) Presents or causes to be presented to any insurer, any written or oral statement including computer-generated documents as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, knowing that such statement contains false, incomplete or misleading information concerning any fact or thing material to such claim; or

(2) Assists, abets, solicits or conspires with another to prepare or make any written or oral statement that is intended to be presented to any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, knowing that such statement contains any false, incomplete or misleading information concerning any fact or thing material to such claim.

Insurance fraud is a class G felony.

(b) All insurance claims forms shall contain a statement that clearly states in substance the following: "Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony." The lack of such a statement shall not constitute a defense against prosecution under this section.

(c) For the purposes of this section, "statement" includes, but is not limited to, a police report, any notice, statement, proof of loss, bill of lading, receipt for payment, invoice, account, estimate of property damages, bill for services, diagnosis, prescription, hospital or doctor records, X rays, test result or other evidence of loss, injury or expense; "insurer" shall include, but is not limited to, a health service corporation or health maintenance organization; and "insurance policy" shall include, but is not limited to, the subscriber and members contracts of health service corporations and health maintenance organizations.

64 Del. Laws, c. 194; 67 Del. Laws, c. 130, § 8; 70 Del. Laws, c. 186, § 1.;

§ 913A Health care fraud; class B felony; class D felony; class G felony.

(a) A person is guilty of health care fraud when the person knowingly:

(1) Presents or causes to be presented any fraudulent health care claim to any health care benefit program; or

(2) Engages in a pattern of presenting or causing to be presented fraudulent health care claims to any health care benefit program.

(b) For the purpose of this section:

(1) "Fraudulent health care claim" means any statement, whether written, oral or in any other form, which is made as part of or in support of a claim or request for payment from any health care benefit program when such statement knowingly contains false, incomplete or misleading information concerning any fact or thing material to such claim.

(2) "Health care benefit program" means any plan or contract, whether public or private, under which any medical benefit, equipment, medication or service is provided to any individual. "Health care benefit program" also includes any individual or entity who is providing a medical benefit, equipment, medication or service for which payment may be made under a plan or contract for the provision of such benefits or services.

(3) "Health care professional," "health care practice," "health care facility" or "health care services" includes but is not limited to any person who or entity which, for payment, practices in or employs the procedures of medicine, surgery, chiropractic, podiatry, dentistry, optometry, psychology, social work, pharmacy, nursing, physical therapy or any other field concerned with the maintenance or restoration of the health of the body or mind.

(4) "Health care provider" means any health care professional, an owner or operator of a health care practice or facility, any person who creates the impression that the person or the person's practice or facility can provide health care services, or any person employed or acting on behalf of any of the aforementioned persons.

(5) "Pattern of presenting or causing to be presented" means 3 or more instances of conduct that constitute presenting or causing to be presented fraudulent health care claims.

(c)(1) Except as provided in paragraphs (2) and (3) of this subsection, health care fraud is a class G felony.

(2) Health care fraud is a class D felony if the elements of subsection (a) of this section are met and if:

a. The intended loss to the health care benefit program is more than $50,000 but less than $100,000;

b. The offender is a health care provider at the time of the offense or offenses; or,

c. The conduct constitutes a pattern of presenting or causing to be presented fraudulent health care claims.

(3) Health care fraud is a class B felony if the elements of subsection (a) of this section are met and if:

a. The intended loss to the health care benefit program is $100,000 or more; or

b. The offender is a health care provider at the time of the offense or offenses and the conduct constitutes a pattern of presenting or causing to be presented fraudulent health care claims.

(4) In addition to the penalties otherwise authorized by this subsection, a person convicted under this section may be subject to a fine of up to 5 times the pecuniary benefit obtained or sought to be obtained through the person's violation of this section.

(d) A conviction is not required for an act of presenting or causing presentation of a fraudulent health care claim to be used in prosecution of a matter under this section, including an act used as proof of a pattern as defined in paragraph (b)(3) of this section. A conviction for any act of presenting or causing presentation of fraudulent health care claims, including one which may be relied upon to establish a pattern of presenting or causing presentation of a fraudulent health care claim, does not preclude prosecution under this section. Prosecution under this section does not preclude prosecution under any other section of the Code.

72 Del. Laws, c. 337, § 1; 70 Del. Laws, c. 186, § 1; 78 Del. Laws, c. 353, §§ 3-5.;