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tdlawyer
tdlawyer, Lawyer
Category: Law
Satisfied Customers: 1096
Experience:  11 years experience of general practice.
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Hi, a friend of mine (really!!) has put in some claims to a

Resolved Question:

Hi, a friend of mine (really!!) has put in some claims to a health insurance company, some of which were true and some not. The total of the false claims is around £5-10k over a couple of years or so. She received a letter recently saying that her most recent claim (for £150) has been suspended pending investigation, as they had received information that lead them to believe they had been given false information by her. At this point she doesn't know if they are only querying the latest claim, or if the will go back and check every claim she has made over the last few years.

Her main question is: if the insurance company decide that a false claim or claims have been made, what action are they likely to take? Will they just demand repayment of any fraudulently claimed amounts, and then if she pays them back in full, leave it at that? Or do you think they may take the case for criminal prosecution? (My own feeling is that they'd rather just have the money back and not go to the bother of criminal prosecution, but I have no experience of this.)
Submitted: 3 years ago.
Category: Law
Expert:  tdlawyer replied 3 years ago.

tdlawyer :

Hello, my name is XXXXX XXXXX I will answer your question for you.

Customer:

Hi Tony,. thanks for getting back to me

tdlawyer :

This depends on the extent of any potential fraud.

tdlawyer :

You can imagine, insurance companies see fraud all the time, there are many millions of false claims put through all the time I expect.

Customer:

As I say, I think it's about 5 to 10,000

tdlawyer :

The police couldn't seriously investigate them all and they woudn't report them all.

Customer:

ok

tdlawyer :

I expect the insurer is probably content to be repair, rather then go through a criminal prosecution, so I agree with your thoughts.

tdlawyer :

They could, however, report it and if this is a sustained pattern of deception which is clear, then there is a risk of prosecution also.

Customer:

This only relates to one company, but several claims; so not quite sure what you mean by a 'pattern'. It did go on for a couple of years with this company. Also, do you think it likely the company will go over all the previous claims, and check them with the various hospitals etc?

tdlawyer :

It depends on what signs they think exist of fraudulent conduct - if any. They might just check the £150 superficially, you just don't know.

Customer:

Ok, so to sum up - the most likely thing is that they will be satisfied with being repaid (and at most that will be the full 5K or whatever); but they may report it to the police, in which case it would be for the police/cps to decide whether to also investigate and prosecute?

tdlawyer :

Yes, that is how I see it. If they do uncover various abuses though and your friend contests it and doesn't pay back, then they might go to the police as if they prosecute and secure a conviction, then they will use that in civil proceedings to recover the money due. They don't have to prove it again in civil proceedings you see, they can just refer to the criminal conviction.

Customer:

Well I don't think my friend would contest it - she was thinking that she would just settle with them, but would like assurance that they would not then pursue the matter further if she repays in full. I don't know whether an agreement like that can be drafted? (Without prejudice, of course.)

tdlawyer :

No, you can't do that, it is against public policy and woulnd't be enforceable. However, that said, I doubt that the insurer would have much interest to a police prosecution if they were repaid. They would share the information with other insurers and it would be difficult I expect for her to get insurance elsewhere.

Customer:

Thank you. One final question - should she reply to their initial letter (which just says the matter is being investigated and that they may ask for further info), or just leave it and see what they say next?

tdlawyer :

I don't think there is anything she can usefully say is there? Maybe it's best to just leave it and wait.

Customer:

Ok yes that's what I thought. Thanks for your help!

tdlawyer :

Thank you and I hope she gets a good resolution. Woud you rate the answer for me please before leaving the chat?

Customer:

Yes sure

tdlawyer :

Thanks - bye.

tdlawyer, Lawyer
Category: Law
Satisfied Customers: 1096
Experience: 11 years experience of general practice.
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