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PENAL CODE
CHAPTER 35. INSURANCE FRAUD
Sec. 35.01. DEFINITIONS. In this chapter:
(1) "Insurance policy" means a written instrument in which is provided the
terms of any certificate of insurance, binder of coverage, contract of insurance,
benefit plan, nonprofit hospital service plan, motor club service plan, surety
bond, cash bond, or any other alternative to insurance authorized by Chapter
601, Transportation Code. The term includes any instrument authorized to be
regulated by the Texas Department of Insurance.
(2) "Insurer" has the meaning assigned by Article 1.02, Insurance Code.
(3) "Statement" means an oral or written communication or a record or
documented representation of fact made to an insurer. The term includes
computer-generated information.
(4) "Value of the claim" means the total dollar amount of a claim for payment
under an insurance policy or, as applicable, the value of the claim determined
under Section 35.025.
Added by Acts 1995, 74th Leg., ch. 621, Sec. 1, eff. Sept. 1, 1995. Amended
by Acts 2001, 77th Leg., ch. 1420, Sec. 14.830, eff. Sept. 1, 2001; Acts 2003,
78th Leg., ch. 1276, Sec. 10A.541, eff. Sept. 1, 2003; Acts 2005, 79th Leg.,
ch. 1162, Sec. 4, eff. Sept. 1, 2005.
Sec. 35.015. MATERIALITY. A statement is material for the purposes of this
chapter, regardless of the admissibility of the statement at trial, if the
statement could have affected:
(1) the eligibility for coverage or amount of the payment on a claim for
payment under an insurance policy; or
(2) the decision of an insurer whether to issue an insurance policy.
Added by Acts 2005, 79th Leg., ch. 1162, Sec. 4, eff. Sept. 1, 2005.
Sec. 35.02. INSURANCE FRAUD. (a) A person commits an offense if, with intent
to defraud or deceive an insurer, the person, in support of a claim for payment
under an insurance policy:
(1) prepares or causes to be prepared a statement that:
(A) the person knows contains false or misleading material information; and
(B) is presented to an insurer; or
(2) presents or causes to be presented to an insurer a statement that the
person knows contains false or misleading material information.
(a-1) A person commits an offense if the person, with intent to defraud or
deceive an insurer and in support of an application for an insurance policy:
(1) prepares or causes to be prepared a statement that:
(A) the person knows contains false or misleading material information; and
(B) is presented to an insurer; or
(2) presents or causes to be presented to an insurer a statement that the
person knows contains false or misleading material information.
(b) A person commits an offense if, with intent to defraud or deceive an
insurer, the person solicits, offers, pays, or receives a benefit in connection
with the furnishing of goods or services for which a claim for payment is
submitted under an insurance policy.
(c) An offense under Subsection (a) or (b) is:
(1) a Class C misdemeanor if the value of the claim is less than $50;
(2) a Class B misdemeanor if the value of the claim is $50 or more but less
than $500;
(3) a Class A misdemeanor if the value of the claim is $500 or more but less
than $1,500;
(4) a state jail felony if the value of the claim is $1,500 or more but less than
$20,000;
(5) a felony of the third degree if the value of the claim is $20,000 or more
but less than $100,000;
(6) a felony of the second degree if the value of the claim is $100,000 or more
but less than $200,000; or
(7) a felony of the first degree if:
(A) the value of the claim is $200,000 or more; or
(B) an act committed in connection with the commission of the offense places
a person at risk of death or serious bodily injury.
(d) An offense under Subsection (a-1) is a state jail felony.
(e) The court shall order a defendant convicted of an offense under this
section to pay restitution, including court costs and attorney's fees, to an
affected insurer.
(f) If conduct that constitutes an offense under this section also constitutes
an offense under any other law, the actor may be prosecuted under this
section, the other law, or both.
(g) For purposes of this section, if the actor proves by a preponderance of the
evidence that a portion of the claim for payment under an insurance policy
resulted from a valid loss, injury, expense, or service covered by the policy,
the value of the claim is equal to the difference between the total claim
amount and the amount of the valid portion of the claim.
(h) If it is shown on the trial of an offense under this section that the actor
submitted a bill for goods or services in support of a claim for payment under
an insurance policy to the insurer issuing the policy, a rebuttable presumption
exists that the actor caused the claim for payment to be prepared or
presented.
Added by Acts 1995, 74th Leg., ch. 621, Sec. 1, eff. Sept. 1, 1995. Amended
by Acts 2003, 78th Leg., ch. 605, Sec. 1, eff. Sept. 1, 2003; Acts 2005, 79th
Leg., ch. 1162, Sec. 4, eff. Sept. 1, 2005.
Sec. 35.025. VALUE OF CLAIM. (a) Except as provided by Subsection (b) and
subject to Subsection (c), for the purposes of Section 35.02(c), if the value of
a claim is not readily ascertainable, the value of the claim is:
(1) the fair market value, at the time and place of the offense, of the goods or
services that are the subject of the claim; or
(2) the cost of replacing the goods or services that are the subject of the
claim within a reasonable time after the claim.
(b) If goods or services that are the subject of a claim cannot be reasonably
ascertained under Subsection (a), the goods or services are considered to
have a value of $500 or more but less than $1,500.
(c) If the actor proves by a preponderance of the evidence that a portion of
the claim for payment under an insurance policy resulted from a valid loss,
injury, expense, or service covered by the policy, the value of the claim is
equal to the difference between the total claim amount and the amount of the
valid portion of the claim.
Added by Acts 2005, 79th Leg., ch. 1162, Sec. 4, eff. Sept. 1, 2005.
Sec. 35.03. AGGREGATION AND MULTIPLE OFFENSES. (a) When separate
claims in violation of this chapter are communicated to an insurer or group of
insurers pursuant to one scheme or continuing course of conduct, the conduct
may be considered as one offense and the value of the claims aggregated in
determining the classification of the offense. If claims are aggregated under
this subsection, Subsection (b) shall not apply.
(b) When three or more separate claims in violation of this chapter are
communicated to an insurer or group of insurers pursuant to one scheme or
continuing course of conduct, the conduct may be considered as one offense,
and the classification of the offense shall be one category higher than the
most serious single offense proven from the separate claims, except that if
the most serious offense is a felony of the first degree, the offense is a felony
of the first degree. This subsection shall not be applied if claims are
aggregated under Subsection (a).
Added by Acts 1995, 74th Leg., ch. 621, Sec. 1, eff. Sept. 1, 1995.
Sec. 35.04. JURISDICTION OF ATTORNEY GENERAL. (a) The attorney general
may offer to an attorney representing the state in the prosecution of an
offense under Section 35.02 the investigative, technical, and litigation
assistance of the attorney general's office.
(b) The attorney general may prosecute or assist in the prosecution of an
offense under Section 35.02 on the request of the attorney representing the
state described by Subsection (a).
Added by Acts 1995, 74th Leg., ch. 621, Sec. 1, eff. Sept. 1, 1995.
CHAPTER 35. INSURANCE FRAUD
Sec. 35.01. DEFINITIONS. In this chapter:
(1) "Insurance policy" means a written instrument in which is provided the
terms of any certificate of insurance, binder of coverage, contract of insurance,
benefit plan, nonprofit hospital service plan, motor club service plan, surety
bond, cash bond, or any other alternative to insurance authorized by Chapter
601, Transportation Code. The term includes any instrument authorized to be
regulated by the Texas Department of Insurance.
(2) "Insurer" has the meaning assigned by Article 1.02, Insurance Code.
(3) "Statement" means an oral or written communication or a record or
documented representation of fact made to an insurer. The term includes
computer-generated information.
(4) "Value of the claim" means the total dollar amount of a claim for payment
under an insurance policy or, as applicable, the value of the claim determined
under Section 35.025.
Added by Acts 1995, 74th Leg., ch. 621, Sec. 1, eff. Sept. 1, 1995. Amended
by Acts 2001, 77th Leg., ch. 1420, Sec. 14.830, eff. Sept. 1, 2001; Acts 2003,
78th Leg., ch. 1276, Sec. 10A.541, eff. Sept. 1, 2003; Acts 2005, 79th Leg.,
ch. 1162, Sec. 4, eff. Sept. 1, 2005.
Sec. 35.015. MATERIALITY. A statement is material for the purposes of this
chapter, regardless of the admissibility of the statement at trial, if the
statement could have affected:
(1) the eligibility for coverage or amount of the payment on a claim for
payment under an insurance policy; or
(2) the decision of an insurer whether to issue an insurance policy.
Added by Acts 2005, 79th Leg., ch. 1162, Sec. 4, eff. Sept. 1, 2005.
Sec. 35.02. INSURANCE FRAUD. (a) A person commits an offense if, with intent
to defraud or deceive an insurer, the person, in support of a claim for payment
under an insurance policy:
(1) prepares or causes to be prepared a statement that:
(A) the person knows contains false or misleading material information; and
(B) is presented to an insurer; or
(2) presents or causes to be presented to an insurer a statement that the
person knows contains false or misleading material information.
(a-1) A person commits an offense if the person, with intent to defraud or
deceive an insurer and in support of an application for an insurance policy:
(1) prepares or causes to be prepared a statement that:
(A) the person knows contains false or misleading material information; and
(B) is presented to an insurer; or
(2) presents or causes to be presented to an insurer a statement that the
person knows contains false or misleading material information.
(b) A person commits an offense if, with intent to defraud or deceive an
insurer, the person solicits, offers, pays, or receives a benefit in connection
with the furnishing of goods or services for which a claim for payment is
submitted under an insurance policy.
(c) An offense under Subsection (a) or (b) is:
(1) a Class C misdemeanor if the value of the claim is less than $50;
(2) a Class B misdemeanor if the value of the claim is $50 or more but less
than $500;
(3) a Class A misdemeanor if the value of the claim is $500 or more but less
than $1,500;
(4) a state jail felony if the value of the claim is $1,500 or more but less than
$20,000;
(5) a felony of the third degree if the value of the claim is $20,000 or more
but less than $100,000;
(6) a felony of the second degree if the value of the claim is $100,000 or more
but less than $200,000; or
(7) a felony of the first degree if:
(A) the value of the claim is $200,000 or more; or
(B) an act committed in connection with the commission of the offense places
a person at risk of death or serious bodily injury.
(d) An offense under Subsection (a-1) is a state jail felony.
(e) The court shall order a defendant convicted of an offense under this
section to pay restitution, including court costs and attorney's fees, to an
affected insurer.
(f) If conduct that constitutes an offense under this section also constitutes
an offense under any other law, the actor may be prosecuted under this
section, the other law, or both.
(g) For purposes of this section, if the actor proves by a preponderance of the
evidence that a portion of the claim for payment under an insurance policy
resulted from a valid loss, injury, expense, or service covered by the policy,
the value of the claim is equal to the difference between the total claim
amount and the amount of the valid portion of the claim.
(h) If it is shown on the trial of an offense under this section that the actor
submitted a bill for goods or services in support of a claim for payment under
an insurance policy to the insurer issuing the policy, a rebuttable presumption
exists that the actor caused the claim for payment to be prepared or
presented.
Added by Acts 1995, 74th Leg., ch. 621, Sec. 1, eff. Sept. 1, 1995. Amended
by Acts 2003, 78th Leg., ch. 605, Sec. 1, eff. Sept. 1, 2003; Acts 2005, 79th
Leg., ch. 1162, Sec. 4, eff. Sept. 1, 2005.
Sec. 35.025. VALUE OF CLAIM. (a) Except as provided by Subsection (b) and
subject to Subsection (c), for the purposes of Section 35.02(c), if the value of
a claim is not readily ascertainable, the value of the claim is:
(1) the fair market value, at the time and place of the offense, of the goods or
services that are the subject of the claim; or
(2) the cost of replacing the goods or services that are the subject of the
claim within a reasonable time after the claim.
(b) If goods or services that are the subject of a claim cannot be reasonably
ascertained under Subsection (a), the goods or services are considered to
have a value of $500 or more but less than $1,500.
(c) If the actor proves by a preponderance of the evidence that a portion of
the claim for payment under an insurance policy resulted from a valid loss,
injury, expense, or service covered by the policy, the value of the claim is
equal to the difference between the total claim amount and the amount of the
valid portion of the claim.
Added by Acts 2005, 79th Leg., ch. 1162, Sec. 4, eff. Sept. 1, 2005.
Sec. 35.03. AGGREGATION AND MULTIPLE OFFENSES. (a) When separate
claims in violation of this chapter are communicated to an insurer or group of
insurers pursuant to one scheme or continuing course of conduct, the conduct
may be considered as one offense and the value of the claims aggregated in
determining the classification of the offense. If claims are aggregated under
this subsection, Subsection (b) shall not apply.
(b) When three or more separate claims in violation of this chapter are
communicated to an insurer or group of insurers pursuant to one scheme or
continuing course of conduct, the conduct may be considered as one offense,
and the classification of the offense shall be one category higher than the
most serious single offense proven from the separate claims, except that if
the most serious offense is a felony of the first degree, the offense is a felony
of the first degree. This subsection shall not be applied if claims are
aggregated under Subsection (a).
Added by Acts 1995, 74th Leg., ch. 621, Sec. 1, eff. Sept. 1, 1995.
Sec. 35.04. JURISDICTION OF ATTORNEY GENERAL. (a) The attorney general
may offer to an attorney representing the state in the prosecution of an
offense under Section 35.02 the investigative, technical, and litigation
assistance of the attorney general's office.
(b) The attorney general may prosecute or assist in the prosecution of an
offense under Section 35.02 on the request of the attorney representing the
state described by Subsection (a).
Added by Acts 1995, 74th Leg., ch. 621, Sec. 1, eff. Sept. 1, 1995.