Member Dental Claim Form - Highmark Blog (Page 2 of 4) in pdf

Any person who knowingly and with intent to defraud any insurance company or other person files

an application for insurance or statement of claim containing any materially false information or

conceals for the purpose of misleading, information concerning any fact material thereto, commits a

fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties.

CA: For your protection California law requires that the following appear on the form: Any person

who knowingly presents a false claim for the payment of a loss is guilty of a crime and may be

subject to fines and confinement in state prison.

DC & RI: Any person who knowingly presents a false or fraudulent claim for payment of a loss or

benefit or knowingly presents false information in an application for insurance is guilty of a

crime and may be subject to fines and confinement in prison.

FL: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a

statement of claim or an application containing any false, incomplete or misleading information

is guilty of a felony in the third degree.

IN & OK: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive an

insurer, makes any claim for the proceeds of an insurance policy containing any false,

incomplete or misleading information is guilty of a felony.

KY: Any person who knowingly and with intent to defraud any insurance company or other person

files a statement of claim containing any materially false information or conceals, for the

purpose of misleading, information concerning any fact material thereto commits a fraudulent

insurance act, which is a crime.

LA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit

or knowingly presents false information in an application for insurance is guilty of a crime and

may be subject to fines and confinement in prison.

NJ: Any person who knowingly files a statement of claim containing any false or misleading

information is subject to criminal and civil penalties.

NY: Any person who knowingly and with intent to defraud any insurance company or other person

files an application for insurance or statement of claim containing any materially false

information, or conceals for the purpose of misleading, information concerning any fact

material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject

to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each

such violation.

VA: Any person who within the intent to defraud or knowing that he is facilitating a fraud against

an insurer, submits an application or files a claim containing a false or deceptive statement may

have violated the state law.

TN & WA: It is a crime to knowingly provide false, incomplete or misleading information to an

insurance company for the purpose of defrauding the company. Penalties include imprison-

ment, fines and denial of insurance benefits.

MD: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss

or benefit or who knowingly or willfully presents false information in an application for

insurance is guilty of a crime and may be subject to fines and confinement in prison.

AZ: For your protection Arizona law requires the following statement to appear on this form. Any

person who knowingly presents a false or fraudulent claim for payment of a loss is subject to

criminal and civil penalties.

Member Dental Claim Form - Highmark Blog Page 2