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1. They are benefits, not entitlements.

Both employees and employers pay into private health-benefits plans. Just because part of your pay cheque goes into your plan, that does not mean you are entitled to use the benefits unconditionally. Pay careful attention to your policy’s limits and rules. Some services, such as massage therapy, require a prescription from a physician. Make sure you review your coverage before submitting claims.

2. Never misrepresent or substitute services.

Most services have a maximum yearly coverage. If you reach the maximum coverage for one service, you cannot misrepresent a claim to rely on coverage for another service. For example: if you have up to $500 in massage therapy and physiotherapy per year, and you run out of insurance-covered massages, do not submit claims for subsequent massages as physiotherapy treatments. Misrepresenting the service provided, even if you have eligible coverage for the service claimed, could be considered a criminal offence.

3. Never fabricate claims or receipts.

Submitting a claim for a service that was never provided could be treated as an outright fraud. Forging receipts, invoices, or prescriptions to support a service that was not provided would constitute an additional criminal offence. Forging documents or using forged documents is a criminal offence. Likewise, sharing a service provider’s registration number with other individuals who intend to submit false claims could be considered a criminal offence.

4. You can be investigated by the insurance company.

Insurance companies conduct random audits of their plan members. In some cases, specific service providers or clinics may be red-flagged and any claims originating from them may be subject to additional scrutiny. In other cases, you may simply be selected for a random audit. Any irregularities or concerns with your claims can result in investigators reviewing your entire claim history, going back years. As a result, you may be contacted by investigators who want to speak with you or who demand to see supporting documentation.

5. The onus is on you.

If an insurance company believes that false or misleading claims were submitted, the onus is on you to prove that the service occurred. The service provider may no longer have records of your treatment or may claim that the service was not provided. Investigators will contact the service provider to obtain written confirmation whether the service was provided. You may also be faced with demands from an insurance company to repay any unsubstantiated claims.

6. You jeopardize your employment.

Submitting false or misleading claims can result in the termination of your employment. The insurance company will notify your employer if they believe that you have submitted false claims or committed insurance fraud. You can be summoned to meetings with Human Resources and confronted with allegations of fraud. Your employer can launch their own investigation. The failure to cooperate or provide an adequate explanation can result in your termination.

7. What you say and do can be used against you

Any interactions you have with your employer or insurance company can be used against you. That includes any statements made to insurance investigators, interviews with HR, e-mails, letters, text messages, or other documents or communications provided voluntarily. Any admission or acknowledgement of wrongdoing could be used against you in a civil or criminal proceeding. Any person that you speak to about these issues can be subpoenaed to testify against you.

8. You can be sued

If an insurance company alleges that an over-payment was made for claims that could not be substantiated, there is the risk that they will commence a civil action against you to recover any outstanding funds should you fail to make a repayment. You may receive a demand letter and a short deadline to provide a full repayment. Never ignore a demand letter from an insurance company, as the failure to respond may result in a lawsuit being filed against you.

9. You can be charged

Insurance companies, employers, and service providers can all refer allegations of insurance fraud to the police. Being investigated for criminal offences relating to insurance fraud is a serious matter. If you are charged, your liberty may be in jeopardy. Criminal offences such as fraud over $5,000, forging documents, and uttering forged documents each carry significant penalties, including jail sentences. Being charged with any criminal offence is a serious matter that can be devastating to your professional reputation and family.

10. You should seek immediate legal assistance

Whether you have received a letter from an insurance company that your claims are being audited or you have been contacted by a police officer, you should seek the immediate assistance of lawyers experienced with insurance fraud matters. Responding to insurance investigators, HR, and police officers is not something that you should do without legal assistance. Anything you say or do can be used against you. A lawyer can negotiate a resolution with your insurance company or employer to protect your legal rights as much as possible. You should never wait until you’ve been charged to retain a lawyer.

The lawyers at Damien Frost & Associates LLP are experienced in handling insurance fraud and health benefits misuse cases, whether you are being investigated by your insurance company, employer, or the police. Contact our office to schedule a free consultation to learn how our lawyers can help you.

By: Daniel Libman -

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