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Insurance fraud is any intentional act to deceive an insurance company to receive money or other benefits to which a person is not entitled. In Buffalo, which is located in Erie County in the state of New York, insurance fraud is treated seriously by both criminal prosecutors and civil authorities. Allegations can arise from many contexts - motor vehicle accidents, homeowners claims, health insurance and medical billing, workers compensation, life insurance, and business insurance. Depending on the nature and value of the alleged fraud, cases can lead to criminal charges, civil lawsuits, administrative penalties and restitution requirements.
This guide explains why someone might need a lawyer, the local legal landscape you should be aware of, common questions people have, helpful resources in the Buffalo area and practical next steps if you are facing an insurance fraud matter or investigation.
Insurance fraud matters can become complex quickly. A lawyer can help in several common situations:
- You have been accused of submitting a false or exaggerated insurance claim. Even an inadvertent misstatement can trigger an investigation and you need legal advice before speaking further with insurers or investigators.
- You are under criminal investigation by local police, the county prosecutor, or state investigators. Criminal charges can carry jail time, fines and a criminal record.
- You received a civil demand or lawsuit from an insurer seeking repayment or damages because the insurer alleges fraud.
- You face administrative actions - for example, if you hold a professional license and an insurer or regulator alleges fraud related to your work.
- You were involved in an accident that looks suspicious to insurers - staged accidents, phantom passengers or coordinated claims can prompt criminal probes.
- You are an employer or business accused of falsifying loss information or payroll for premium reduction or enhanced recovery.
In each of these situations an experienced lawyer can advise you on your rights, communicate with investigators and insurers on your behalf, preserve evidence, identify defenses and negotiate outcomes that minimize legal, financial and professional harm.
Insurance fraud in Buffalo is governed primarily by New York State law. Key points to understand:
- Criminal and civil law apply - New York treats certain fraudulent insurance acts as crimes and also allows insurers to sue to recover losses. Penalties may include fines, restitution, probation and imprisonment for serious offenses.
- Level of offense often depends on the loss amount and intent - small misrepresentations may lead to misdemeanors, while schemes that involve significant sums, repeated acts or organized activity can lead to felony charges.
- Intent to deceive is central - to prove criminal insurance fraud prosecutors normally must show that a person knowingly and willfully made false statements or submissions intending to gain money or avoid an obligation.
- Investigations can be conducted by multiple agencies - local police, the Erie County District Attorney, state insurance regulators and state investigators may all be involved depending on the facts. In cases involving federal programs or multi-state schemes, federal agencies may participate.
- Civil remedies and administrative penalties are possible even without criminal charges - an insurer can deny claims, seek recovery in court, and state regulators can impose fines or licensing consequences on individuals and businesses.
- Cooperation and statements matter - written statements, sworn affidavits, recorded interviews and social media posts can be used as evidence. Speaking without legal advice can worsen your position.
Insurance fraud includes knowingly making false or misleading statements to obtain an insurance benefit, inflating claims, staging accidents, submitting fake invoices, falsifying medical records, hiding material facts on an application and using another person’s identity to file claims. Both individuals and businesses can commit fraud.
Penalties vary based on the severity and the amount involved. Consequences can include fines, restitution to the insurer, probation, and jail or prison time for felony-level offenses. Convictions can also lead to loss of professional licenses, higher insurance costs and a criminal record that affects employment and housing.
Yes. Intentionally inflating damages or misrepresenting facts to increase a payout can result in criminal charges. Even if the initial falsification seems minor, repeated exaggerations or a deliberate scheme raise the risk of a serious charge.
Do not admit fault or provide additional statements without legal counsel. Preserve all documents and communications related to the claim. Contact a lawyer experienced in insurance fraud matters as soon as possible to review the insurer’s allegations and advise on a response strategy.
Not always. Investigations can begin with interviews, requests for documents and claims audits. Arrests typically occur when prosecutors believe they have sufficient evidence to charge someone. Still, because investigations can lead to charges, early legal advice is important.
Insurers may deny claims or rescind a policy if material misrepresentations appear on the application. Whether a mistake is material depends on whether the misstatement would have affected the insurer’s decision or premium. A lawyer can help argue that an error was innocent or immaterial, or negotiate a fair resolution.
Investigations often start with a claim review by the insurer. If fraud is suspected, insurers may refer the matter to investigators or law enforcement. Local police, the Erie County District Attorney’s Office and state regulators may investigate further. Investigations can include interviews, subpoenas for records and collaboration with medical providers or employers.
Common defenses include lack of intent to defraud, honest mistake, insufficient evidence, identity theft or third-party fraud, and the insurer’s failure to follow required procedures. An attorney will review the facts and may negotiate a reduced charge, dismissal or a plea that limits consequences.
Look for criminal defense or insurance defense attorneys with experience handling insurance fraud matters. Check local bar association referral services, read attorney biographies and reviews, and ask about relevant case experience, typical outcomes and fee structures. Many lawyers offer an initial consultation to evaluate your case.
Gather all claim-related documents - insurance policies, claim forms, correspondence with the insurer, bills, repair estimates, medical records, photos, police reports, eyewitness statements and any receipts or logs. Keep electronic communications and preserve social media posts that relate to the claim. Do not alter or destroy evidence.
Below are agencies and organizations that can provide information, oversight or assistance in insurance fraud matters in Buffalo and New York State:
- Erie County District Attorney - prosecutes criminal matters in Buffalo and can provide public information about ongoing initiatives and how investigations proceed.
- Erie County law enforcement agencies - local police departments investigate accidents and alleged criminal conduct.
- New York State Department of Financial Services - oversees insurance regulation in New York State and handles certain consumer complaints and regulatory enforcement.
- New York State Attorney General - participates in enforcement against fraudulent schemes and can provide consumer guidance.
- National Insurance Crime Bureau - a not-for-profit organization that collects data on insurance fraud and can be a resource on national trends and reporting.
- Erie County Bar Association Lawyer Referral Service and New York State Bar Association - for finding qualified lawyers and legal referral options.
- Local legal aid organizations and public defender offices - if you cannot afford private counsel, these organizations can advise on eligibility for free or low-cost legal representation.
- New York State Unified Court System - for information about court procedures if a case goes to trial or civil litigation.
If you are facing an allegation of insurance fraud or believe you are under investigation, here are practical next steps:
- Pause communications - do not provide additional statements to insurers, investigators or other parties without speaking to a lawyer.
- Preserve evidence - collect and safely store all documents, records, photographs and electronic messages related to the claim.
- Get legal help - seek an attorney experienced in insurance fraud, criminal defense or insurance litigation. If you cannot afford private counsel, contact public defenders or local legal aid groups to explore options.
- Prepare for interviews carefully - your lawyer can advise whether to cooperate, how to respond to subpoenas and whether to negotiate with prosecutors or insurers.
- Understand potential outcomes - discuss likely scenarios with your lawyer, including dismissal, plea agreements, civil settlement, restitution or trial.
- Respond to civil demands separately - if an insurer sends a demand letter or files a civil case, you may need both criminal defense and civil counsel to protect your interests.
- Act promptly - early steps to preserve evidence and retain counsel often improve the chances of a favorable outcome.
Disclaimer - This guide is for general informational purposes and does not constitute legal advice. Laws change and every situation is different. Consult a qualified attorney in Buffalo to get advice tailored to your particular circumstances.
