Insurance fraud is aggressively investigated and prosecuted in Pennsylvania. With the insurance industry losing an estimated $30 billion annually due to fraud, insurers are highly motivated to pursue suspected fraudulent claims, sometimes even when the accusations are exaggerated or unfounded. If you’re being investigated or have already been charged, protecting yourself with experienced legal representation is critical.
We know how high the stakes are at Worgul, Sarna & Ness, Criminal Defense Attorneys. A conviction could mean prison time, hefty fines, and lasting damage to your personal and professional life. Our Pittsburgh insurance fraud lawyers can help you fight back with a tailored, strategic defense.
What Is Insurance Fraud in Pennsylvania?
In Pennsylvania, insurance fraud is broadly defined under 18 Pa.C.S. § 4117, which makes it a crime to knowingly provide false, incomplete, or misleading information to an insurer or government agency to gain an improper benefit. This includes making false statements during the claim process, application phase, or even while attempting to prevent the detection of fraud.
Fraud doesn’t need to be successful to result in charges; even the attempt or intent to deceive can trigger criminal liability. Additionally, individuals can be prosecuted for helping someone else commit fraud, whether knowingly or unknowingly.
Common Acts of Insurance Fraud Include:
Submitting False Claims
For example, reporting a stolen vehicle that was not actually stolen, or filing a medical claim for treatment that was never received.
Exaggerating Losses
Claiming more extensive damage than actually occurred. This is common in property insurance fraud, such as inflating the cost of repairs after a fire or flood.
Staging Accidents
Intentionally causing or faking a car accident to collect auto insurance payouts, often as part of a larger ring of coordinated fraud involving fake witnesses and medical providers.
Lying on Applications
Providing false information on an insurance application or renewal form — like failing to disclose a prior conviction or misrepresenting the value of insured property.
Using Another Person’s Policy
Filing claims under someone else’s insurance policy without authorization or pretending to be the insured party.
Operating Without a License
Selling or soliciting insurance without being a licensed broker or agent is illegal and often tied to broader fraudulent activity.
Runner or Capper Schemes
Participating in organized fraud rings that recruit individuals to file fake personal injury claims after real or staged accidents, often coordinated with unethical doctors, lawyers, or repair shops.
Depending on the complexity and scope of the alleged scheme, insurance fraud is often linked to other criminal charges, such as identity theft, wire fraud, conspiracy, and money laundering.
How Are Insurance Fraud Cases Investigated?
Insurance fraud investigations are typically complex, lengthy, and highly coordinated. Insurance companies invest heavily in anti-fraud efforts, often initiating internal investigations before involving law enforcement.
Key Players in Investigations:
- Special Investigative Units (SIUs): Most major insurers have in-house fraud detection teams who analyze claim data, verify evidence, and look for red flags.
- Law Enforcement Agencies: Local police, the Pennsylvania Attorney General’s Insurance Fraud Section, and federal agencies like the FBI and Department of Justice are often involved in larger or multi-jurisdictional cases.
- National Insurance Crime Bureau (NICB): This nonprofit agency partners with insurers and law enforcement to detect fraud trends and uncover organized fraud rings.
Common Investigation Techniques:
Surveillance
Investigators may monitor your daily activities to compare against claims. For example, if someone claims a debilitating back injury but is later filmed lifting heavy objects, that evidence could be used to discredit the claim.
Data Mining
Advanced software is used to flag inconsistencies, duplicate claims, or patterns that suggest fraudulent behavior.
Recorded Interviews & Statements
Investigators may contact you for a “routine” interview, but these are often strategic efforts to get you to make inconsistent or incriminating statements.
Subpoenas & Search Warrants
Prosecutors may obtain warrants for financial records, phone logs, or internal business communications in criminal cases.
Investigators often build a case quietly, gathering as much documentation and testimony as possible before filing charges. This is why many people are blindsided when they’re suddenly arrested or indicted — the case has been developing in the background for months, if not longer.
Penalties for Insurance Fraud in Pennsylvania
Pennsylvania takes insurance fraud seriously. Under state law, penalties are determined based on factors such as the amount of financial loss, intent, and whether the fraud involved a pattern or organized scheme.
Criminal Penalties:
- Felony of the Third Degree:
- Up to 7 years in prison
- Fines up to $15,000
- Applies when the fraud involves significant financial harm or deliberate, sustained deception.
- Misdemeanor of the First Degree:
- Up to 5 years in prison
- Fines up to $10,000
- Applies to smaller-scale offenses or attempts that did not result in substantial financial loss.
Civil Penalties & Restitution:
In addition to criminal charges, individuals may face civil lawsuits brought by insurance companies. These may include demands for:
- Restitution: Repayment of the amount allegedly obtained through fraud.
- Triple Damages: Under specific laws, victims may be awarded three times the financial loss if fraud is part of a broader scheme.
- Investigation Costs & Attorney Fees: You may be forced to cover the cost of the investigation and the insurer’s legal expenses.
Collateral Consequences:
- Loss of professional licenses (particularly in healthcare, finance, or law)
- Permanent criminal record
- Damage to reputation and creditworthiness
- Difficulty obtaining employment or housing
The stakes are especially high for licensed professionals, such as doctors, chiropractors, and insurance agents, who may face criminal charges and license suspension or revocation by regulatory boards.
Facing Insurance Fraud Charges? Don’t Wait to Act.
Unlike some criminal offenses, insurance fraud charges often follow lengthy investigations involving surveillance, audits, and interviews. If investigators have contacted you or believe you’re being watched, do not speak to anyone without a lawyer — anything you say can be used against you later.
You may be at risk of prosecution at both the state and federal levels, especially if the alleged fraud crosses state lines, involves government programs, or includes large financial sums.
Why Choose Worgul, Sarna & Ness?
Our defense attorneys bring decades of experience fighting serious fraud allegations in Pennsylvania courts. We understand how prosecutors build their cases — and how to dismantle them. Whether we’re challenging the validity of the evidence, highlighting investigative overreach, or negotiating for reduced charges, we fight to protect your freedom and future.
Talk to a Pittsburgh Insurance Fraud Lawyer Today
If you’re facing an insurance fraud investigation or charges, time is not on your side. You need a defense attorney who knows the law, understands the system, and can build a solid defense to protect your rights.
Call us now at (412) 281-2146 or email us at advice@pittsburghcriminalattorney.com for a free and confidential consultation.
We’re here to help you through every step — with discretion, experience, and the determination to get results.
