Louisiana Revised Statutes 23:1200.2 – Prohibited activities and sanctions; duties of group self-insurance funds and others; civil immunity; definitions
Terms Used In Louisiana Revised Statutes 23:1200.2
- Accident: means an unexpected or unforeseen actual, identifiable, precipitous event happening suddenly or violently, with or without human fault, and directly producing at the time objective findings of an injury which is more than simply a gradual deterioration or progressive degeneration. See Louisiana Revised Statutes 23:1021
- Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
- Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Fraud: Intentional deception resulting in injury to another.
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
- Office: means the office of workers' compensation administration established pursuant to La. See Louisiana Revised Statutes 23:1021
- person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
- Statement: includes but is not limited to any notice, statement, proof of loss, bill of lading, receipt for payment, invoice, account, estimate of property damages, bill for services, diagnosis, prescription, hospital or doctor records, test results, X-rays, or other evidence of loss, injury, or expense. See Louisiana Revised Statutes 23:1200.2
- Tort: A civil wrong or breach of a duty to another person, as outlined by law. A very common tort is negligent operation of a motor vehicle that results in property damage and personal injury in an automobile accident.
A. Any person who, with the intent to injure, defraud, or deceive any group self-insurance fund, or any member employer, or other party in interest, or any third party claimant:
(1) Presents or causes to be presented any written or oral statement including computer-generated documents as part of or in support of or denial of a claim for payment or other benefit pursuant to a coverage agreement, knowing that such statement contains any false, incomplete, or fraudulent information concerning any fact or thing material to such claim; or
(2) Assists, abets, solicits, or conspires with another to prepare or make any written or oral statement that is intended to be presented to any group self-insurance fund, member employer, or other party in interest or third party claimant in connection with, or in support of or denial, or any claim for payment of other benefit pursuant to a coverage agreement, knowing that such statement contains any false, incomplete, or fraudulent information concerning any fact or thing material to such claim;
is guilty of a felony and shall be subjected to a term of imprisonment, with or without hard labor, not to exceed five years, or a fine not to exceed five thousand dollars, or both, on each count.
B. Any person, group self-insurance fund, or other legal entity subject to this Subpart who believes that a fraudulent claim is being made, shall within sixty days of the receipt of such notice, send to the section of insurance fraud of the Department of Insurance, on a form prescribed by the section, the information requested and such additional information relative to the claim and the parties claiming loss or damages because of an occurrence and/or accident as the section may require. The section of insurance fraud shall review such reports and select such claims as, in its judgment, may require further investigation. It shall then cause an independent examination of the facts surrounding such claim to be made to determine the extent, if any, to which fraud, deceit, or intentional misrepresentation of any kind exists in the submission of the claim. The section of insurance fraud shall report any alleged violations of law which its investigations disclose to the appropriate licensing agency and prosecutive authority having jurisdiction with respect to any such violation.
C.(1) No group self-insurance fund, its employees, agents, or any other person acting without malice, fraudulent intent, or bad faith, shall be subject to civil liability for libel, slander, or any other relevant tort, and no civil cause of action of any nature shall exist against such person or entity by virtue of the filing of reports or furnishing other information, either orally or in writing, concerning suspected, anticipated, or completed fraudulent insurance acts when such reports or information are required by this Subpart or required by the section of insurance fraud as a result of the authority herein granted or when such reports or information are provided to or received from:
(a) Law enforcement officials, their agents, and employees.
(b) The National Association of Insurance Commissioners, the state Department of Insurance, a federal or state agency or bureau established to detect and prevent fraudulent insurance acts, as well as any other organization established for the same purpose, their agents, employees, or designees.
(2) The immunity herein granted does not abrogate or modify in any way any statutory or other privilege or immunity otherwise enjoyed by such person or entity.
(3) Any person or entity covered by the provisions of this Section shall be entitled to an award of attorney fees and costs if they are the prevailing party in a civil suit and the party bringing the action was not substantially justified in doing so. For the purposes of this Subsection, a proceeding is “substantially justified” if it had a reasonable basis in law or fact at the time it was initiated.
D. As used in this Subpart the following terms shall have the meanings indicated herein:
(1) “Fraudulent insurance act” shall include but not be limited to acts or omissions committed by any person who, knowingly and with intent to defraud:
(a) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, reinsurer, purported insurer or reinsurer, broker, group self-insurance fund, or any agent thereof, any oral or written statement which he knows to contain materially false information as part of, or in support of, or denial of, or concerning any fact material to or conceals any information concerning any fact material to the following:
(i) An application for the issuance of any insurance policy or coverage agreement.
(ii) The rating of any insurance policy or coverage agreement.
(iii) A claim for payment or benefit pursuant to any insurance policy or coverage agreement.
(iv) Premiums paid on any insurance policy or coverage agreement.
(v) Payments made in accordance with the terms of any insurance policy or coverage agreement.
(vi) The financial condition of any insurer, reinsurer, purported insurer or reinsurer.
(vii) The acquisition of any insurer or reinsurer.
(b) Solicits or accepts new or renewal group self-insurance risks by or for an insolvent group self-insurance fund.
(c) Removes or attempts to remove the assets or record of assets, transactions, and affairs of such material part thereof, from the home office or other place of business of the group self-insurance fund, or from the place of safekeeping of the group self-insurance fund or who conceals or attempts to conceal the same from the department.
(d) Diverts, attempts to divert, or conspires to divert funds of a group self-insurance fund, in connection with:
(i) The transaction of group self-insurance.
(ii) The conduct of business activities by a group self-insurance fund.
(iii) The formation, acquisition, or dissolution of a group self-insurance fund.
(e) Supplies false or fraudulent material or information pertaining to any document or statement required by the Department of Insurance.
(2) “Statement” includes but is not limited to any notice, statement, proof of loss, bill of lading, receipt for payment, invoice, account, estimate of property damages, bill for services, diagnosis, prescription, hospital or doctor records, test results, X-rays, or other evidence of loss, injury, or expense.
Acts 1995, No. 327, §1.