Fraud: Intentional deception resulting in injury to another.
Insurance: includes :
(i)
a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;
(ii)
a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and
(iii)
a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301
Insurer: means any person or aggregation of persons:
(a)
doing insurance business, as defined in Section 31A-1-301; or
(b)
subject to the supervision of the commissioner under:
(i)
this title; or
(ii)
any equivalent insurance supervisory official of another state. See Utah Code 31A-31-102
Restitution: The court-ordered payment of money by the defendant to the victim for damages caused by the criminal action.
Security: means a:
(i)
note;
(ii)
stock;
(iii)
bond;
(iv)
debenture;
(v)
evidence of indebtedness;
(vi)
certificate of interest or participation in a profit-sharing agreement;
(vii)
collateral-trust certificate;
(viii)
preorganization certificate or subscription;
(ix)
transferable share;
(x)
investment contract;
(xi)
voting trust certificate;
(xii)
certificate of deposit for a security;
(xiii)
certificate of interest of participation in an oil, gas, or mining title or lease or in payments out of production under such a title or lease;
(xiv)
commodity contract or commodity option;
(xv)
certificate of interest or participation in, temporary or interim certificate for, receipt for, guarantee of, or warrant or right to subscribe to or purchase any of the items listed in Subsections (171)(a)(i) through (xiv); or
(xvi)
another interest or instrument commonly known as a security. See Utah Code 31A-1-301
State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
(2)
The insurance antifraud plan required by Subsection (1) shall outline specific procedures, actions, and safeguards that include how the authorized insurer or health maintenance organization will do each of the following:
(a)
detect, investigate, and prevent all forms of insurance fraud, including:
(i)
fraud involving its employees or agents;
(ii)
fraud resulting from misrepresentations in the application, renewal, or rating of insurance policies;
(iii)
fraudulent claims; and
(iv)
breach of security of its data processing systems;
(b)
educate employees of fraud detection and the insurance antifraud plan;
(c)
provide for fraud investigations, whether through the use of internal fraud investigators or third-party contractors;
(d)
report a suspected fraudulent insurance act, as described in Section 31A-31-103, to the department as required by Section 31A-31-110; and
(e)
pursue restitution for financial loss caused by insurance fraud.
(3)
The commissioner may investigate and examine the records and operations of authorized insurers and health maintenance organizations to determine if they have implemented and complied with the insurance antifraud plan.
(4)
The commissioner may:
(a)
direct any modification to the insurance antifraud plan necessary to comply with the requirements of this section; and
(b)
require action to remedy substantial noncompliance with the insurance antifraud plan.
