By: Harris, Chris S.B. No. 208
73R2136 DLF-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the offense of insurance claim fraud; providing a
1-3 criminal penalty.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter D, Chapter 32, Penal Code, is amended
1-6 by adding Section 32.55 to read as follows:
1-7 Sec. 32.55. INSURANCE CLAIM FRAUD. (a) A person commits an
1-8 offense if the person, with intent to injure, defraud, or deceive
1-9 an insurer, prepares or presents to an insurer in support of a
1-10 claim for payment under an insurance policy a statement that the
1-11 person knows:
1-12 (1) contains false or misleading information
1-13 concerning a matter that is material to the claim; or
1-14 (2) conceals or fails to disclose a material fact that
1-15 affects:
1-16 (A) a person's right to a payment; or
1-17 (B) the amount of a payment to which a person is
1-18 entitled.
1-19 (b) A person commits an offense if the person, with the
1-20 intent to injure, defraud, or deceive an insurer, solicits, offers,
1-21 pays, or receives a benefit in connection with the furnishing of
1-22 health care goods or services for which payment is sought under an
1-23 insurance policy.
1-24 (c) For the purposes of Subsection (a) of this section,
2-1 information concerning a matter that is material to a claim for
2-2 payment under an insurance policy includes information concerning:
2-3 (1) whether health care goods or services were
2-4 medically necessary under professionally accepted standards;
2-5 (2) whether health care goods or services were
2-6 provided;
2-7 (3) the nature of the health care goods or services
2-8 provided;
2-9 (4) the date on which health care goods or services
2-10 were provided;
2-11 (5) the medical record of goods or services provided;
2-12 (6) the condition treated or diagnosis made; or
2-13 (7) the identity of the provider or the recipient of
2-14 health care goods or services.
2-15 (d) Except as provided by Subsection (e) of this section, an
2-16 offense under this section is:
2-17 (1) a Class C misdemeanor if the value of the claim is
2-18 less than $20;
2-19 (2) a Class B misdemeanor if:
2-20 (A) the value of the claim is $20 or more but
2-21 less than $200; or
2-22 (B) the value of the claim is less than $20 and
2-23 the actor has been previously convicted of a misdemeanor under this
2-24 section;
2-25 (3) a Class A misdemeanor if the value of the claim is
2-26 $200 or more but less than $750;
2-27 (4) a felony of the third degree if:
3-1 (A) the value of the claim is $750 or more but
3-2 less than $20,000; or
3-3 (B) the value of the claim is less than $750 and
3-4 the actor has been previously convicted of a misdemeanor two or
3-5 more times under this section;
3-6 (5) a felony of the second degree if the value of the
3-7 claim is $20,000 or more but less than $100,000; or
3-8 (6) a felony of the first degree if:
3-9 (A) the value of the claim is $100,000 or more;
3-10 (B) the value of the claim is less than $100,000
3-11 and the actor has been previously convicted of a felony under this
3-12 section; or
3-13 (C) the value of the claim is less than $100,000
3-14 and the commission of the offense placed a person at risk of death
3-15 or serious bodily injury.
3-16 (e) An offense under this section is, if the actor is a
3-17 health care practitioner:
3-18 (1) a felony of the third degree if the value of the
3-19 claim is less than $20,000;
3-20 (2) a felony of the second degree if the value of the
3-21 claim is $20,000 or more but less than $100,000; or
3-22 (3) a felony of the first degree if:
3-23 (A) the value of the claim is $100,000 or more;
3-24 (B) the value of the claim is less than $100,000
3-25 and the actor has been previously convicted of an offense under
3-26 this section; or
3-27 (C) the value of the claim is less than $100,000
4-1 and the commission of the offense placed a person at risk of death
4-2 or serious bodily injury.
4-3 (f) In this section:
4-4 (1) "Insurer" means any person who does business as an
4-5 insurer in this state, including an insurer that is not authorized
4-6 to do business in this state. The term includes a health
4-7 maintenance organization, a company subject to Chapter 20,
4-8 Insurance Code, and an organization that is self-insured and that
4-9 provides health care benefits to its employees.
4-10 (2) "Health care practitioner" means a person who
4-11 renders or causes to be rendered health care or mental health care
4-12 services and who is entitled to payment under a health insurance
4-13 policy. The term includes:
4-14 (A) any person who may be selected by an insured
4-15 or beneficiary under Article 21.52, Insurance Code; and
4-16 (B) an officer, employee, or agent of an
4-17 organization that renders health care or mental health care
4-18 services.
4-19 (3) "Statement" means any written representation of
4-20 fact, including a notice, proof of loss, bill of lading, receipt
4-21 for payment, invoice, account, estimate of property damages, bill
4-22 for services, diagnosis, prescription, medical record, X-ray, test
4-23 result, or other evidence of loss, injury, or expense. A statement
4-24 may be computer-generated.
4-25 SECTION 2. The change in law made by Section 32.55, Penal
4-26 Code, as added by this Act, applies only to the punishment for an
4-27 offense committed on or after the effective date of this Act. For
5-1 the purpose of this section, an offense is committed before the
5-2 effective date of this Act if any element of the offense occurs
5-3 before the effective date. An offense committed before the
5-4 effective date of this Act is covered by the law in effect when the
5-5 offense was committed, and the former law is continued in effect
5-6 for this purpose.
5-7 SECTION 3. This Act takes effect September 1, 1993.
5-8 SECTION 4. The importance of this legislation and the
5-9 crowded condition of the calendars in both houses create an
5-10 emergency and an imperative public necessity that the
5-11 constitutional rule requiring bills to be read on three several
5-12 days in each house be suspended, and this rule is hereby suspended.