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Recognize it Report it Protect yourself NCDOI
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The N C Department of Insurance would like,to thank the North Carolina Association of. Insurance Agents Inc for its generous support,1 250 copies of this document were printed. using 2 740 of NCAIA Surplus Grant monies, Insurance fraud in North Carolina is big business in. fact sadly it is a growing enterprise that costs each. of us dearly With approximately 10 percent of all,insurance claims involving some degree of fraud. totaling nearly 120 billion per year lost we all, pay for this deceit in the form of added insurance.
Fraud occurs in every area of our insurance needs, from health care insurance to property and casualty. insurance life and disability insurance Criminals,exist with successful scams for every part of the. industry and each of us pay as a result Also because North Carolina citizens. have endured hurricanes floods and other natural disasters we know. firsthand that there are opportunists out there who are hitting us while we re. Your Department of Insurance is charged with maintaining order in the. North Carolina insurance market I am proud of the fact that our fight to. keep insurance rates down has been largely successful and one of the. most important components of the effort to keep these rates down is our. fight against fraud Our Criminal Investigations Division has the mission of. conducting criminal investigations and supporting prosecution of persons. or other entities committing insurance related crimes Department of. Insurance Special Agents are committed professionals who are dedicated to. our cause and who take pride in our successes, This brochure outlines some of the ways to recognize report and protect. yourself from insurance fraud I encourage you to read it and to contact the. Department for assistance whenever necessary, As the Senior Deputy Commissioner over the NCDOI Fraud Control Group. my staff and I are honored to carry out Commissioner Causey s Mission of. combating Fraud The Fraud Control Group is staffed and organized into four. divisions Criminal Investigation Division Criminal Legal Services Division. Bail Bond Regulatory Division and Special Services Review Division The. Fraud Control Group is here to serve and maintains a customer service. oriented mantra This book is filled with pertinent information to assist you. and we encourage you to contact us for any questions you may have. MARTY SUMNER,SENIOR DEPUTY COMMISSIONER,FRAUD CONTROL GROUP.
SENIOR DEPUTY COMMISSIONER,EXECUTIVE PROFESSIONAL,ASSISTANT STANDARDS. CRIMINAL CRIMINAL BAIL BOND SPECIAL SERVICES, INVESTIGATIONS LEGAL SERVICES REGULATORY REVIEW DIVISION. DIVISION DIVISION DIVISION DIRECTOR CPA CFE,DEPUTY COMMISS DEPUTY COMMISS. ADMINISTRATIVE PARALEGAL ADMINISTRATIVE,ASSISTANT ASSOCIATE. DISTRICT SUPPORT LICENSING,OPERATIONS SERVICES ATTORNEY SPECIALISTS.
DIVISION CHIEF DIVISION CHIEF 2 CIVILIANS,DISTRICT I SPECIAL COMPLAINTS. COMMANDER OPERATIONS ATTORNEY ANALYSTS, 7 SPECIAL AGENTS OSFM 2 AGENTS DISTRICTS I II 4 CIVILIANS. BAIL BOND 2 AGENTS,DISTRICT II CRIME ATTORNEY,COMMANDER ANALYST DISTRICTS III IV. 7 SPECIAL AGENTS,DISTRICT III FORENSIC,COMMANDER ACCOUNTANT. 7 SPECIAL AGENTS CPA CFE,DISTRICT IV RESERVE,COMMANDER PROGRAM.
7 SPECIAL AGENTS 1 SPECIAL AGENT,DISTRICT II DISTRICT III. DISTRICT I,DISTRICT IV,FRAUD CONTROL GROUP,CONTACT US. If you have any questions about insurance fraud or. would like to report suspected insurance fraud please. contact the North Carolina Department of Insurance. Criminal Investigations Division The Division is, headquartered in Raleigh and we have Special Agents. based throughout the state We depend on citizens and. industry representatives to report illegal and suspicious. insurance related activities Tips can be reported,anonymously. CRIMINAL INVESTIGATIONS DIVISION,NC Department of Insurance.
1201 Mail Service Center,Raleigh NC 27699 1201,reportfraud ncdoi gov. 888 680 7684 Toll free,919 807 6840 Outside of NC,919 715 1156 Fax. Criminal Investigations Division 1,Criminal Legal Services Division 1. Bail Bond Regulatory Division 2,Special Services Review Division 3. COMMON INSURANCE FRAUD SCHEMES,Automobile Insurance Fraud 5.
Billing of Medical Services 5,Property Claims Adjusting and Property Repair 6. Miscellaneous Insurance Fraud 7,How to Spot and Avoid a Con Artist 8. Protect Yourself 11,CRIMINAL INVESTIGATIONS DIVISION. The North Carolina Department of Insurance Criminal Investigations. Division CID is the nation s oldest and one of the most respected state. insurance department fraud units in the country Founded in 1945 the. Division is charged with conducting criminal investigations and supporting. prosecution of individuals and entities committing insurance related crimes. throughout North Carolina and across the country, Investigative personnel are sworn law enforcement officers having statewide. jurisdiction The Special Agents are fully authorized to carry firearms make. arrests conduct searches and present cases at all levels of prosecution. The Special Agents work in close cooperation with the insurance industry. state and federal law enforcement agencies and prosecutors The Division. remains actively involved in conducting fraud investigations that pertain to. natural catastrophes staged automobile accidents body and repair shops. medical providers agent embezzlement unauthorized insurers insider. fraud durable medical equipment suppliers and more You may know. certain individuals who try to take advantage of the system by submitting. fraudulent claims and justifying their actions with comments such as. Insurance companies are huge they can afford this My premiums are. too high I ll show them Everybody does it what s the big deal THE. BIG DEAL is that we all pay for fraud and we must take steps to reduce it by. reporting it, In an environment where our citizens are victimized by insurance fraud or.
in some cases even seem to condone it our mission becomes increasingly. difficult Difficult or not the Criminal Investigations Division remains. committed to the identification and prosecution of those responsible for. insurance fraud,CRIMINAL LEGAL SERVICES DIVISION, The North Carolina Department of Insurance Criminal Legal Services Division. CLSD is comprised of three attorneys and one paralegal Session Law 2017. 197 House Bill 528 Council of State Special Prosecutor Pilot Project allows. the Administrative Office of the Courts in consultation with the Conference. of District Attorneys to appoint up to two special prosecutors per Council of. State member These special prosecutors aid local district attorneys offices in. prosecuting insurance fraud cases that arise under Article 15 of Chapter 14. of the North Carolina General Statutes violations of Chapter 58 of the North. 1 FIGHTING FRAUD FOR YOU, Carolina General Statutes and violations of Chapter 14 of the North Carolina. General Statutes, NCDOI Criminal Legal Services Division has two attorneys that are appointed. as special prosecutors The attorneys work with state district attorneys to. present evidence gathered by the Criminal Investigations Division Bail. Bond Regulatory Division or other DOI Divisions in an attempt to fully. prosecute the insurance and or bail bonds crimes that the department has. investigated The special prosecutors are sworn in over 33 counties and. actively work on more than 70 cases The special prosecutors serve as the. lead prosecutor on cases as appropriate The attorneys work directly with the. NCDOI Senior Deputy of the Fraud Control Group,BAIL BOND REGULATORY DIVISION. The primary purpose of the Bail Bond Regulatory Division BBRD is to. regulate educate and enforce all aspects of bail bonding The Division. ensures proper and fair treatment has been given to individuals who are. involved within the North Carolina legal bail bond system BBRD regulates. all Professional Bail Bondsmen Bail Bond Runners and Surety Bondsmen. licensed to operate in North Carolina Also all Surety Insurance Companies. licensed to conduct business in N C are regulated by the Department of. Insurance NCDOI All persons acting in any capacity of bail bonding must. be licensed by the Commissioner of Insurance, North Carolina currently has two public and three private education.
providers offering pre licensing education PLE and continuing education. CE for bail bondsmen The Bail Bond Regulatory Division monitors closely. these institutions to ensure all curriculum being taught is accurate up to. date and non biased Each person who becomes licensed as a bondsman is. considered an officer of the court and will be expected to carry themselves. as a professional at all times, NCDOI is proactive in that it ensures bail bonding adheres strictly to N C. General Statutes established by the N C General Assembly under GS. 58 71 1 200 All written complaints received are reviewed and appropriate. action is taken This Division works closely with our Criminal Investigations. Division Criminal Legal Services Division and the Attorney General s office. BBRD also works with local county and state law enforcement. To submit complaints contact bbrdinbox ncdoi gov or visit. ncdoi com BB Online Complaint aspx,FIGHTING FRAUD FOR YOU 2. SPECIAL SERVICES REVIEW DIVISION, The Special Services Review Division is the newest addition to the Fraud. Control Group This division provides an in depth review of financial and. various other records of insurance companies insurance agents or bail. bondsmen based on referred cases These come from citizen complaints. other DOI organizational units outside agencies insurance companies. insurance agents or other sources Results of these reviews could lead. to additional actions by NCDOI or referral to the Criminal Investigations. The Special Services Review Division works closely with other NCDOI. divisions and collaborates with other state departments of insurance to help. determine unlawful activity or patterns of violations that could negatively. impact North Carolina citizens and policyholders,3 FIGHTING FRAUD FOR YOU. INSURANCE FRAUD,AUTOMOBILE INSURANCE FRAUD,AUTOMOBILE REPAIR.
Review all repair shop paperwork carefully Concerns noted in this area may. involve one or more of the following,Falsely reporting lost or damaged parts. Billing for excessive final cost, Providing final statement containing false and or unauthorized charges. Charging for genuine parts when aftermarket or junkyard parts were. actually used,Charging for new parts when bonding or pounding. Referring customers to medical or legal offices for a fee. AUTOMOBILE ACCIDENTS, Individuals and or organized accident rings that stage auto accidents. involving one or more of the following,Sudden stops in front of you for no reason.
Disregarding or giving up right of way to cause an accident. No real accident occurred on paper only with phony drivers and. passengers more popular now due to less of a chance of actual injury. and less likelihood of police involvement, Claims that list drivers passengers witnesses who do not exist and who. claim excessive injuries especially when compared to vehicle damage. Driver has temporary vehicle registration and there is prior damage to. one or both vehicles, Unsolicited referrals or contacts by from or to body shops legal offices. and medical offices, Fraudulently reporting vehicles as stolen or vandalized in order to collect. insurance money,BILLING OF MEDICAL SERVICES, A variety of dishonest techniques may be used to fraudulently bill the. consumer his or her insurance company and or public programs Medicare. Medicaid etc for, Treatment not provided or provided by someone other than doctor.
Alternative treatment provided,Tests or supplies not conducted or provided. Cancellation charge for unscheduled visits,Charges for office visits not made. Referral fees for services not rendered,Unnecessary lab or other testing. 5 FIGHTING FRAUD FOR YOU,PROPERTY CLAIMS ADJUSTING. This type of fraud has been extremely prolific in North Carolina due to. hurricane related damage, Fraudulent claims adjusting usually involves illegal or questionable methods.
Operating as an adjuster without the required license. Adjuster requests that his or her name be the payee of the insurance. Adjuster requests that the payee endorse the insurance check over to. him or her, Adjuster handles all business in person has no telephone number. address or other means of contact and avoids use of mail. Claim check larger than cost of repairs made, Invoices include charges for services not rendered or for repairs not made. PROPERTY REPAIR, This type of fraud usually involves unethical or incompetent building. contractors Take caution if, Contractor has no office or other legitimate place of contact to include. telephone number address residence references etc and avoids use of. Contractor requests full payment up front, Contractor arrives at site unsolicited and often does not have proper.
equipment or supplies for the job, Contractor unwilling to show or does not have license or liability. Contractor provides a very general estimate,Bid seems too good to be true. FIGHTING FRAUD FOR YOU 6,MISCELLANEOUS INSURANCE FRAUD. Life and disability fraud embezzlement false pretense false statements. willful failure to pay group insurance premiums and other insurance related. crimes are occurring every day in North Carolina For example. Instances where an insurance agent has not forwarded premiums. to the appropriate insurance company as required by contract This. situation often leads to charges of embezzlement and on occasion has. caused entire agencies to become financially impaired and incapable of. conducting further business, Instances where an employer has willfully stopped paying premiums. on employee group insurance plans without first having given the. employees at least a 45 day written notice As a result employees are. unaware they no longer have insurance coverage when the insurance. company cancels the group policy for non payment Often the first sign. of this occurs when the hospital or other medical provider informs the. employee that their coverage has been terminated and that they are now. responsible for the entire bill, The practice of convincing an insured to use an existing policy s cash.
value to pay for a newer and unnecessary policy is called churning or. twisting Since agents earn their largest commission for the first year a. policy is in effect unscrupulous agents may twist the truth and churn a. new better or cheaper policy to the customer This new policy may in. fact have less favorable terms or fewer benefits This is illegal. Unauthorized insurers are companies plans or other arrangements. that give the appearance of being authorized licensed registered. or approved by state or federal regulators to engage in the business. of transacting insurance In other words they look and act like legal. insurance companies however they are unlicensed and may often. engage in illegal acts They often offer substantially lower rates and. employ few if any underwriting principles As a result claims are paid. slowly or not at all and cash reserves are non existent after having been. misappropriated by unscrupulous owners Regulation by state regulators. and the United States Department of Labor is rigorously avoided and. sooner or later the entity goes out of business leaving their insureds. high and dry with unpaid claims and no insurance,7 FIGHTING FRAUD FOR YOU.


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