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Employment Benefits Insurance Fraud

Employees often receive a benefits plan through their employer for health care services such as dental, massage therapy, physiotherapy, optometry, and orthopedics. Issues arise, however, when employees are investigated by the insurance company for unsubstantiated claims.

It may come to your attention that you are being audited or investigated by an insurance company in a number of ways. For example, you may be informed by one of your health practitioners that they have received inquiries about your claims for paramedical, dental, and other services. You may also be contacted by an Investigator from an insurance company by phone, email or in person about your claims. You could also be brought into a HR meeting by your employer and asked to explain the claims in question.

Internal Insurance Company Investigations

Insurance companies often investigate matters of unsubstantiated claims internally. These investigations often commence by way of routine claims audits. The insurance company may contact you requesting additional information or supporting documentation for a number of claims that you previously made. It is important to contact a lawyer early on in this investigation process. A lawyer will provide you with important legal advice before you speak to an insurance investigator or your employer about any health benefits claims issues.

Employment Consequences

Allegations of insurance benefits fraud can have a significant impact on your livelihood, your career, and your family. An allegation of insurance benefits fraud could result in being charged with criminal offences, being terminated from your employment, or being sued by the insurance company. Criminal penalties can result in a criminal record, which can further impact your future career prospects.

Criminal Penalties or Civil Lawsuit for Insurance Fraud

An insurance company or your employer could also commence a civil lawsuit against you for fraud and may seek the recovery of any funds that were lost.

An insurance company can also forward their investigation to police, who may decide to lay charges for fraud. (Link to Fraud Over $5000 page) A conviction arising from insurance fraud charges can also result in a number of penalties, depending on your previous criminal record. If you have previously been involved in fraud, the chances of incarceration increase. If you have no prior convictions or a compelling personal circumstance, a conviction could result in a lesser fine or other penalty.

Contact a Toronto Insurance Fraud defence Lawyer

To arrange a free initial consultation with Damien R. Frost & Associates, call 416-923-1900 or contact the legal defence firm via email today.

I was charged along with nine other physicians with fraud against OHIP. I was also the subject of a complaint before the College of Physicians and Surgeons arising from the same allegations. I was assigned counsel by the Canadian Medical Protective Association (CMPA). On the advice of a friend who was a Crown Counsel I insisted that I be allowed to retain Mr. Frost. I am very pleased that I was allowed to do so. Mr. Frost (together with Ms. Samantha Peeris) provided me with first class representation. He convinced the Crown to drop the charges against me. His office always kept me informed in a timely fashion of any developments. He clearly understood the impact of these allegations on my professional reputation. Mr. Frost always maintained a very low profile. Mr. Frost went on to represent me before the College of Physicians and Surgeons ensuring that no disciplinary was taken. I continue to practice medicine in my area of expertise.

Dr. C.

Members of The Criminal Lawyers Association, Toronto Lawyers Association, Ontario Bar Association 
and Advocates' Society.

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