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Criminal Jury Instructions

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10.6-2  Health Insurance Fraud -- § 53-442

Revised to December 1, 2007

The defendant is charged [in count __] with health insurance fraud.  The statute defining this offense provides in pertinent part as follows: 

a person is guilty of health insurance fraud when (he/she), with the intent to defraud or deceive any insurer, <insert as appropriate:>

  • (presents / causes to be presented) to any (insurer / insurer's agent) any written or oral statement as part of or in support of (an application for / claim for payment or other benefit from) a plan providing health care benefits, whether for (himself/herself), a family member or a third party, knowing that such statement contains any false, incomplete, deceptive or misleading information concerning any fact or thing material to such claim or application, or omits information concerning any fact or thing material to such claim or application

  • (assists / abets / solicits / conspires with) another to prepare or present any written or oral statement to any insurer or any agent thereof, in connection with, or in support of, an application for any policy of insurance or claim for payment or other benefit from a plan providing health care benefits knowing that such statement contains any false, deceptive or misleading information concerning any fact or thing material to such application or claim.

"Person" is defined by statute as any individual, corporation, limited liability company, partnership, association or any other legal entity.1

For you to find the defendant guilty of this charge, the state must prove the following elements beyond a reasonable doubt:

Element 1 - Presented oral or written statement
The first element is that the defendant <insert as appropriate:>

  • (presented / caused to be presented)

  • (assisted / abetted / solicited / conspired) with another to prepare or present

any written or oral statement as part of or in support of an application for any policy of insurance or claim for payment or other benefit from a plan providing health care benefits, whether for himself, a family member or a third party.  "Statement" includes but is not limited to any notice, statement, invoice, account, bill for services, explanation of services, medical opinion, test result, computer generated document, electronic transmission or other evidence of loss, injury or expense.2

Element 2 - To an insurer
The second element is that the statement was presented to an insurer or an insurer's agent.  "Insurer" means any insurance company, health care center, corporation, Lloyd's insurer, fraternal benefit society or any other legal entity authorized to provide health care benefits in this state, including benefits provided under health insurance, disability insurance, workers' compensation and automobile insurance or any person, partnership, association or legal entity which is self-insured and provides health care benefits to its employees or governmental entity which provides medical benefits to Medicare or Medicaid recipients.3

Element 3 - Knowledge
The third element is that the defendant knew that the statement contained false, incomplete, deceptive or misleading information concerning any fact or thing material to such claim or application, or knowingly omitted information concerning any fact or thing material to such claim or application. 

"Misleading information" includes but is not limited to falsely representing that goods or services were medically necessary in accordance with professionally accepted standards.4

A person acts "knowingly" with respect to conduct or circumstances when (he/she) is aware that (his/her) conduct is of such nature or that such circumstances exist.  <See Knowledge, Instruction 2.3-3.>

Element 4 - Intent to defraud
The fourth element is that the defendant did so with the specific intent to defraud or deceive the insurer.  <See Intent to Defraud, Instruction 2.3-6.>

Conclusion

In summary, the state must prove beyond a reasonable doubt that the defendant 1) (presented / caused to be presented) an (oral / written) statement in support of (an application for / claim for payment or other benefit from) a plan providing health care benefits, 2) the statement was presented to an insurer or an insurer's agent, 3) the defendant knew that the statement contained false, incomplete, deceptive or misleading information or omitted information material to the (application / claim), and 4) the defendant intended to defraud the insurer.

If you unanimously find that the state has proved beyond a reasonable doubt each of the elements of the crime of health insurance fraud, then you shall find the defendant guilty.  On the other hand, if you unanimously find that the state has failed to prove beyond a reasonable doubt any of the elements, you shall then find the defendant not guilty.
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1 General Statutes § 53-441 (b).

2 General Statutes § 53-441 (a).

3 General Statutes § 53-441 (c).

4 General Statutes § 53-442.
 


 

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