Missouri Fraud Reporting

Definition of “Fraudulent Insurance Act”

§ 375.991 RSMo. Fraudulent insurance act, committed, when — powers and duties of department — penalties

1. As used in sections 375.991 to 375.994, the term “statement” means any communication, notice statement, proof of loss, bill of lading, receipt for payment, invoice, account, estimate of damages, bills for services, diagnosis, prescription, hospital or doctor records, x-rays, test results or other evidence of loss, injury or expense.

2. For the purposes of sections 375.991 to 375.994, a person commits a “fraudulent insurance act” if such person knowingly presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, purported insurer, broker, or any agent thereof, any oral or written statement including computer generated documents as part of, or in support of, an application for the issuance of, or the rating of, an insurance policy for commercial or personal insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance, which such person knows to contain materially false information concerning any fact material thereto or if such person conceals, for the purpose of misleading another, information concerning any fact material thereto.

3. A “fraudulent insurance act” shall also include but not be limited to knowingly filing false insurance claims with an insurer, health services corporation, or health maintenance organization by engaging in any one or more of the following false billing practices:
. . .

Mandatory Fraud Reporting Statute(s) Section 375.992 RSMo. requires mandatory reporting:

Any company which believes that a fraudulent claim is being made shall, within sixty days of the receipt of such notice, send to the department of insurance, financial institutions and professional registration, on a form prescribed by the department, the information requested and such additional information relative to the claim and the parties claiming loss or damages because of the accident as the department may require. . . .

20 CSR 100-3.100 Fraud Investigation Reports

(1) Insurers must report any allegation of a fraudulent insurance claim to the Consumer Affairs Division using a Fraud Investigation Report by Insurer form (Form F-I) adopted and approved by the director in 20 CSR 100-4.030. This form also may be used by an insurer seeking the department's assistance in the investigation and prosecution alleged fraudulent insurance claims and other types of fraudulent insurance acts.

(2) Any person other than an insurer reporting a fraudulent insurance act to the Consumer Affairs Division must use a Fraud Investigation Report by Consumer form (Form F-C) adopted and approved by the director in 20 CSR 100-4.030.

How to Report Fraud

For Producers reporting fraud concerning another licensee, use the Consumer Complaint form accessible from the Department’s Insurance Complaints webpage.

For Producers reporting fraud concerning a non-licensee, report directly to the National Insurance Crime Bureau.