Insurers faced with a potentially fraudulent claim involving other insurers
are unduly fearful. They fear claims of violation of privacy laws, suits for
bad faith, collusion, governmental actions, and claims of violation of antitrust
laws. They fear suits for false arrest and acting as agents of the state that
caused the National Insurance Crime Bureau (NICB) this year to pay a $1.1 settlement
to two accused insurance fraud perpetrators. The fear deprives the insurer,
fellow insurers, and the public of information that will reduce the effectiveness
of the crime of insurance fraud.
The fear should be put aside and controlled intelligently. The law in the
United States is directed at helping insurers work together and with government
agencies to defeat fraud. In fact, because insurance fraud has become such a
drain on the nation, the law requires insurers to share information about fraud
with each other and the proper authorities. The insurers who refuse to cooperate
misunderstand, in my opinion, the letter and intent of the statutes. They are,
in fact, violating the statutory scheme and contributing to the massive growth
rate of insurance fraud.
Insurers in California, where I practice, and other states with similar insurance
privacy laws, faced with a request from another insurer about the claims or
underwriting history of an insured, imitate the three famous chimps who "See
no evil, hear no evil, and speak no evil." They also render themselves blind,
deaf, and dumb.
Legislative Initiatives
In 1947 the National Association of Insurance Commissioners (NAIC) first
proposed a model Unfair Trade Practices Act. The Unfair Trade Practices Act
combined with the Unfair Claims Settlement Practices Act, work to regulate the
methods of performing the business of insurance and insurance claims. Since
that time, under various revisions, the Unfair Trade Practices Act has been
adopted by almost every jurisdiction in the United States.
The more recent NAIC Insurance Information and Privacy Protection Model Act
(on which the statutes in California and many states are based) was designed
as a shield to protect the innocent insured from unwanted disclosure. It was
not designed as a weapon to use against an insurer attempting to defeat a fraudulent
claim. The scheme designed in the Model Act, and other statutes, encourages
the sharing of information between insurers concerning potential insurance fraud.
The states that have adopted the Act are shown in Figure
1.
| The Model Privacy Act has been adopted in the following states. |
| Arizona [Ariz. Rev. Stat. Ann.
§ 20-2101 to 20-2120 (1981)] |
| Connecticut [Conn. Gen. Stat.
§ 38a-975 to 38a-998 (1981/1983) |
| Georgia [Ga. Code Ann. § 33-39-1
to 33-39-23 (1982/1985)] |
| Hawaii (in part) [Hawaii Rev.
Stat. § 431:17-101 to 431:17-106 (1988)] |
| Illinois [Ill. Rev. Stat. ch.
I.C. § 1001 to 1024 (1981/1982)] |
| Kansas [Kan. Stat. Ann. § 2,111
to 2,113 (1981/1986) (Part of model)] |
| Massachusetts [SB 1667 (1992)] |
| Minnesota [Minn. Stat. § 72A.49
to 72A.505 (1989)] |
| Montana [Mont. Code Ann. § 33-19-101
to 33-19-409 (1982)] |
| Nevada [Nev. Admin. Code § 679B.560
to 679B.750 (1989)] |
| New Jersey [N.J. Rev. Stat. §
17:23A-1 to 17:23A-22 (1985)]; |
| North Carolina [N.C. Gen. Stat.
§ 58-39-1 to 58-39-120 (1981)]; |
| Oregon [Or. Rev. Stat. § 746.600
to 746.690 (1981/1988)] |
| Virginia [Va. Code § 38.2-600
to 38.2-620 (1986/1987)] |
Statutory Schemes Encourage Insurers To Share Information
The intent of the NAIC, the California Legislature, and the Legislatures
of those states that have adopted the Model Act was to encourage the sharing
of information concerning fraud between insurers. Under the Act, insurers may
safely disclose to other insurers almost all information gathered in an investigation
if the reason for the disclosure is to detect or prevent fraudulent or criminal
claims activities. Before a disclosure can be safely made, however, it must
be determined by the insurer that:
- The disclosure is to be made in good faith.
- The disclosure is based on reasonable investigation.
- The disclosure is made without malice.
Such disclosures are not limited to questions of fraud or criminal activity.
Disclosure can also be made in cases of misrepresentation or concealment of
material facts, a fraud attempted (rather than a fraud effected), or an innocent
misrepresentation or concealment.
The NAIC Acts, with their requirements for sharing information with proper
authorities, the establishment of a Special Investigation Unit (SIU) to fight
fraud, and the establishment of an information depository where all insurers
could benefit from the experience of other insurers is an indication, in my
opinion, of a statutory scheme authorizing and encouraging insurers to share
information so that insurance fraud will no longer be financially lucrative
to its perpetrators. These efforts modify the crime by increasing the number
of activities that are considered to be criminal insurance fraud and also by
increasing the penalties for those who are convicted of the crime.
The statutory scheme was enacted with the express purpose of providing the
insurance industry with a reasonable means of combating insurance fraud. By
enacting the Insurance Frauds Prevention Act (IFPA), the California Legislature
(and other states such as New Jersey that have enacted similar statutes), clearly
understood that fraud was a major problem facing the country and that drastic
measures were necessary to reduce insurance fraud. The intent was to provide
the industry with immunities from civil liability if the insurer meets minimum
requirements for investigation and reporting of suspected fraud.
The IFPA even creates a state operated database designed to allow insurers
and the state to share information about potential fraudulent claims without
exposure to litigation for providing the information. This is further indication
that a statutory scheme and policy authorizing the sharing of information concerning
fraud and fraudulent insurance claims exists.
Recommendations
To be effective, statutes relating to the disclosing of insurer information
to another insurer need to ensure the following.
-
The insurer who is requested to share information with another insurer
must have a reasonable belief that fraud, criminal activity, misrepresentation,
or concealment of material fact are being attempted before it may disclose
that information.
-
Before such disclosure is made, the insurer must be satisfied, in accordance
with state and federal law, that the disclosure is made in good faith. The
insurer must have conducted a good faith investigation to establish that
there is good cause for the disclosure.
-
The insurer cannot provide information to another insurer merely because
another insurer asks for it. On the other hand, if an appropriate police
agency demands the information in writing, it not only may, but also must,
disclose the information to the proper police agency.
-
If an appropriate authorization form is signed by the person whose records
are sought to be disclosed, the insurer may always disclose the information.
The delivery of the authorization establishes that the consumer whose privacy
the statutes attempt to protect has given permission to disclose the information.
Further, if the insurers act on the signed authorization of the insured,
the authorization is prima facie evidence of the good faith of the insurers.
Insurers may also, similarly, obtain like information from other insurers
as long as they provide those other insurers with the information necessary
for the other insurer to produce the documents to them in good faith. The
best means of obtaining the information is to have the insured sign an authorization
form that complies with the statute.
-
Disclosure of information, in good faith, to other insurers to prevent
fraud should not be construed by a trier of fact as a violation of the antitrust,
unfair competition, or unfair practices acts. An insurer who is requested
to provide information about an insured, or ex-insured, to another insurer
can do so safely if it establishes the following before making a disclosure:
- The insured has signed an appropriate authorization.
- The insurer seeking the information is doing so in good faith.
- The insurer seeking the information is doing so without any malice
to the insured.
- The insurer seeking the information has sufficiently investigated
to establish that it has sufficient grounds to seek the information.
- The insurer producing the information is doing so in good faith.
- The insurer producing the information is doing so without any malice
to the insured.
- The insurer producing the information has sufficiently investigated
to establish that it has sufficient grounds to convey the information.
If the seven rules stated above are followed, the insurer will, in my opinion,
be in clear compliance with the requirements of the law and will be better equipped
to fight fraud. If rules 2. through 6. are followed the insurer will, in my
opinion, be in compliance with the requirements and spirit of the law. If an
insurer refuses to respond to legitimate requests from other insurers who have
followed the rules indicated above, it can be found to be involved in unfair
business tactics and be subject to fines and suits for damages.
The key to safely disclosing information about an insured, or past insured,
is to apply the rule on which all insurance is based the doctrine of uberrima fides [utmost good faith]. The
insurer who discloses information to other insurers in situations involving
potential fraud does so with the utmost good faith and will comply with both
the spirit and letter of the law.
Police agencies must also remember that the private investigators, the insurers,
and their representatives are an essential part of every insurance fraud investigation.
Information should, and in some cases must, flow in both directions.
*This article is excerpted from a much longer
report on the topic, which delves into the specifics of California statutes
and caselaw. For more information on that report, contact Mr. Zalma at (310)
390-4455 or by e-mail at