§ 176.05 Insurance fraud; defined.
A fraudulent insurance act is committed by any person who, knowingly
and with intent to defraud presents, causes to be presented, or prepares
with knowledge or belief that it will be presented to or by an insurer,
self insurer, or purported insurer, or purported self insurer, or any
agent thereof:
1. any written statement as part of, or in support of, an application
for the issuance of, or the rating of a commercial insurance policy, or
certificate or evidence of self insurance for commercial insurance or
commercial self insurance, or a claim for payment or other benefit
pursuant to an insurance policy or self insurance program for commercial
or personal insurance that he or she knows to:
(a) contain materially false information concerning any fact material
thereto; or
(b) conceal, for the purpose of misleading, information concerning any
fact material thereto; or
2. any written statement or other physical evidence as part of, or in
support of, an application for the issuance of a health insurance
policy, or a policy or contract or other authorization that provides or
allows coverage for, membership or enrollment in, or other services of a
public or private health plan, or a claim for payment, services or other
benefit pursuant to such policy, contract or plan that he or she knows
to:
(a) contain materially false information concerning any material fact
thereto; or
(b) conceal, for the purpose of misleading, information concerning any
fact material thereto.
Such policy or contract or plan or authorization shall include, but
not be limited to, those issued or operating pursuant to any public or
governmentally-sponsored or supported plan for health care coverage or
services or those otherwise issued or operated by entities authorized
pursuant to the public health law. For purposes of this subdivision an
“application for the issuance of a health insurance policy” shall not
include (i) any application for a health insurance policy or contract
approved by the superintendent of financial services pursuant to the
provisions of sections three thousand two hundred sixteen, four thousand
three hundred four, four thousand three hundred twenty-one or four
thousand three hundred twenty-two of the insurance law or any other
application for a health insurance policy or contract approved by the
superintendent of financial services in the individual or direct payment
market; or (ii) any application for a certificate evidencing coverage
under a self-insured plan or under a group contract approved by the
superintendent of financial services.
