Philadelphia Insurance Fraud Defense Attorneys

Insurance Fraud in Philadelphia & Across PA

Most criminal insurance fraud charges in PA are brought under 18 Pa.C.S. § 4117. As the Commonwealth’s primary insurance fraud statute, this law makes it a crime to knowingly provide false, incomplete, or misleading information to an insurer or government agency in connection with an insurance policy or claim, with the intent to defraud.

In some situations, you may also see references to 40 P.S. § 474, an older statute that addresses fraud in procuring insurance or collecting claims, typically as a misdemeanor.

To be convicted of insurance fraud, prosecutors mu prove:

• You knowingly made or helped make a false, misleading, or incomplete statement or document
• The information was material to an insurance transaction or claim
• You acted with intent to defraud an insurer, a self-insured entity, or a government agency.

In Philadelphia, insurance fraud cases are considered as white-collar crimes and frequently involve complex paper trails, financial records, and expert testimony. That makes having a defense lawyer experienced in insurance fraud especially important.

What’s Considered Insurance Fraud?

You can find yourself accused of insurance fraud in many different ways. Some situations involve clear intentional schemes; others are honest mistakes that prosecutors try to treat as crimes. Here are common scenarios:

Auto Insurance Fraud

You might be charged with auto insurance fraud if you report your car as stolen after you’ve actually hidden or sold it, stage or exaggerate a crash and claim injuries you don’t have, say a second vehicle was involved in a hit-and-run when it wasn’t, or submit repair estimates for pre-existing damage.

Health & Medicaid Insurance Fraud

You could face health or Medicaid fraud charges if you use someone else’s insurance card for treatment, or if you’re a provider who bills for services not performed, upcodes procedures, orders unnecessary tests, or bills for equipment or medications never supplied.

Property & Homeowners Insurance Fraud

You might be accused of property or homeowners insurance fraud if you claim items were destroyed that you never owned, exaggerate the value of damaged property, or submit altered receipts or staged photos to inflate a payout.

Workers’ Compensation Insurance Fraud

You may face workers’ comp fraud allegations if you collect benefits while working an undisclosed second job, misrepresent your injuries or limitations, or—if you’re an employer—misclassify employees or hide payroll to avoid premium costs.

Application & Policy Fraud

Even before a claim is filed, you can be charged with insurance fraud if you lie on an application about prior claims, driving history, income, or criminal background, or if you omit important information to secure lower premiums on health, auto, or business insurance.

Business Insurance Fraud (Including PPP Fraud)

You can also be charged with business insurance fraud if you misrepresent company losses, payroll, property damage, or operational status to obtain or increase coverage, inflate a commercial claim, or provide fabricated financial documents.

Although PPP (Paycheck Protection Program) matters are often handled as federal fraud cases, related conduct, such as submitting false payroll, revenue, or business interruption information to insurers can also trigger state-level insurance fraud charges in Pennsylvania, especially when commercial insurance benefits, business-interruption claims, or overlapping financial statements are involved.

Penalties & Consequences for Insurance Fraud in Pennsylvania

Under Pennsylvania law, most insurance fraud charges are treated as felonies of the third degree, carrying severe exposure

• Up to seven years in state prison,
• Fines as high as $15,000, and
• A felony record that can impact employment, licensing, and future insurance coverage.

While certain related conduct (such as violations under 40 P.S. § 474) may be charged as misdemeanors with penalties of up to one year in jail, prosecutors typically pursue the felony statute whenever the facts allow.

Beyond criminal sentencing, the court can also order restitution to the insurer or alleged victim, impose substantial court costs and statutory assessments, and impose additional civil penalties.

Insurance Fraud Civil & Collateral Consequences

The criminal sentence is only part of the picture. An insurance fraud conviction or even a plea can lead to:

• Civil lawsuits from insurers seeking repayment, interest, and attorneys’ fees
• Loss of professional licenses, especially for doctors, nurses, pharmacists, contractors, and other licensed professionals
• Immigration consequences if you’re not a U.S. citizen
• Difficulty obtaining future insurance coverage or facing much higher premiums
• Employment problems, particularly in financial, medical, or government positions
• A lasting criminal record that can affect housing, loans, and background checks

For health care providers or business owners, the fallout from an insurance fraud case can effectively end a practice or career. That’s why it’s critical to treat any investigation or charge as a serious threat from day one.

“Just a Mistake” vs. Criminal Insurance Fraud

Not every error, inconsistency, or misunderstanding in an insurance claim amounts to a crime. Real life is messy, and insurance paperwork can be confusing—even for experienced policyholders, business owners, and licensed professionals. You may honestly misremember the value of property, estimate a loss based on incomplete information, or misunderstand what your adjuster, agent, or medical billing staff was asking for. Many people also rely on outside professionals—such as contractors, coders, office staff, or public adjusters — who may provide incorrect numbers or documentation without any intent to deceive.

Insurance companies often treat these discrepancies as red flags; however, a discrepancy alone does not constitute a criminal case. The law requires prosecutors to prove that you acted knowingly and with intent to defraud, not simply that you provided information that turned out to be wrong. Valuation disputes, coding errors, incomplete documentation, or communication breakdowns between you and a contractor or office employee are often civil matters, not felony-level fraud.

The line between an honest mistake and criminal insurance fraud almost always comes down to intent. A major focus of your defense is demonstrating what was happening behind the scenes, your understanding, your reliance on others, and the absence of any intent to mislead the insurer. Even if something in your claim or application is inaccurate, showing that the mistake was unintentional can be the difference between a simple claim dispute and a serious felony charge.

Who Prosecutes Insurance Fraud in Philadelphia?

In Philadelphia, insurance fraud cases are often handled not by local police or the District Attorney, but by the Pennsylvania Office of Attorney General’s Insurance Fraud Section, a specialized statewide unit that investigates and prosecutes auto, health, property, workers’ compensation, and business insurance fraud.

These prosecutors routinely coordinate with insurer Special Investigations Units (SIUs), federal agencies, and the Pennsylvania Insurance Fraud Prevention Authority, meaning cases typically arrive with extensive documentation and a highly experienced team behind them. The OAG is known for pursuing aggressive sentences and building detailed financial and documentary records before filing charges, defending these cases requires an attorney who understands how the Attorney General develops fraud prosecutions and knows how to challenge their investigative methods, negotiations, and evidence.

What to Expect in an Insurance Fraud Investigation

• The SIU Review: Most cases start when an insurance company’s Special Investigations Unit (SIU) flags a claim and quietly reviews documents, interviews witnesses, or analyzes inconsistencies.
• Referral to the Attorney General: If the insurer suspects fraud, it often refers the case to the Pennsylvania Attorney General’s Insurance Fraud Section, which may begin a formal investigation without notifying you.
• Subpoenas & Interview Requests: Investigators may issue subpoenas for financial, medical, or business records and may request an interview or grand jury appearance—steps you should never take without legal counsel.
• Arrest or Summons: If charges are approved, you may be arrested or mailed a summons to appear in court.
• Arraignment: Charges are read, bail is set, and conditions of release are established.
• Preliminary Hearing: The Commonwealth must show probable cause; your attorney can challenge the evidence, question witnesses, and sometimes negotiate early resolutions.
• Pretrial Motions & Negotiation: Your lawyer may move to suppress evidence, challenge the charges, or negotiate reduced counts, alternative programs, or other favorable outcomes.
• Plea or Trial: If no resolution is reached, the case proceeds to a plea or trial in the Philadelphia Court of Common Pleas.
• Sentencing & Post-Conviction Options: If convicted or if you accept a plea, the court imposes penalties such as jail, probation, fines, and restitution. Your attorney may also pursue appeals or post-conviction relief.

Early legal representation is critical as it can influence what charges are filed, how serious they are, and the overall direction of your case.

Defenses to Insurance Fraud in Pennsylvania

No two insurance fraud cases are the same, but common defense strategies include:

• Lack of Intent to Defraud – Prosecutors must prove you acted with intent to defraud, not just that something you said was wrong. If you relied on another person’s calculations, misunderstood a question, or made an honest mistake, the Commonwealth may not be able to meet its burden.
• No Material Misrepresentation – Even if a statement was incorrect, it must be material, meaning it would have affected the insurer’s decision. If the alleged misstatement had no real impact on coverage or payment, that can weaken the case.
• Insufficient or Unreliable Documentation – Insurance fraud cases are documentation-heavy. If records are incomplete, contradict each other, or were mishandled, your lawyer can highlight those weaknesses.
• Legitimate Valuation Disputes – Insurance claims often involve disagreements over value – especially for property or medical billing. A dispute over what something is worth is not the same as fraud.
• Challenging Witness Credibility – Adjusters, co-defendants, or former employees may have their own motives, including trying to shift blame. Your lawyer can cross-examine them to expose bias or inconsistencies.
• Improper Investigation Practices – If investigators pushed you into making statements without properly advising you of your rights, or if warrants were defective, your attorney may be able to suppress key evidence.

How an Insurance Fraud Lawyer at Fienman Defense Can Help

Facing an insurance fraud investigation or charge requires a defense lawyer who understands how insurers, SIUs, and the Attorney General’s Office build these cases—and how to dismantle them. At Fienman Defense, we provide focused, strategic representation tailored to the complexities of insurance fraud in Pennsylvania.

• Early Intervention – Fienman Defense steps in immediately to protect you before charges are filed, reviewing SIU letters, subpoenas, or investigator requests to ensure you respond effectively. We communicate directly with insurers or the Attorney General’s Office on your behalf, ensuring you don’t unintentionally provide statements or documents that could be used against you. Early guidance helps you decide whether to cooperate, provide records, or decline interviews—often shaping the direction and severity of the case from the start.
• Independent Investigation – We conduct a thorough analysis of all documents related to your claim, including policies, forms, billing records, financial data, and communications. When appropriate, we bring in forensic accountants, coders, or billing experts to clarify technical issues and expose weaknesses in the insurer’s or prosecutor’s theory. This careful review enables us to identify honest errors, valuation disputes, or administrative mistakes that the Commonwealth may misinterpret as intentional fraud.
• Focused Defense Strategy – Your defense is built around a straightforward, fact-driven narrative that highlights misunderstandings, paperwork mistakes, or reliance on third parties—not criminal intent. We evaluate every path toward a favorable outcome, including dismissals, reduced charges, or alternatives that avoid felony convictions. Our strategy emphasizes your lack of intent to defraud, which is often the most critical element in defeating an insurance fraud allegation.
• Aggressive Negotiation – Fienman Defense engages directly with the Attorney General’s Insurance Fraud Section or local prosecutors, advocating for the least severe outcome possible. We work to reduce the number or severity of charges, negotiate restitution terms you can manage, and pursue alternatives to incarceration where appropriate. Our familiarity with how these specialized units build and resolve fraud cases allows us to negotiate from a position of strength.
• Trial-Ready Representation – Every case is prepared as if it may proceed to trial, giving you leverage during negotiations and protection if litigation becomes necessary. We cross-examine investigators, SIU personnel, and expert witnesses to expose gaps, assumptions, or flaws in the Commonwealth’s case. If your case goes before a judge or jury, we present a clear, compelling defense grounded in evidence and credibility.
• Client Support – You receive clear communication, practical guidance, and steady support throughout the entire process. We help you understand your risks and options, protect your professional licenses when applicable, and address collateral consequences such as media exposure or parallel civil actions. If your case overlaps with other allegations—such as identity theft, access device fraud, or SNAP violations—we coordinate a unified defense to safeguard every aspect of your future.

Attorney Fienman’s skill and experience with Pennsylvania’s insurance fraud laws enable him to navigate complex investigations, challenge documentary evidence, and provide clients with informed and strategic defense representation. He understands how insurers, SIUs, and the Attorney General’s Office build these cases and uses that insight to protect clients at every stage of the process.

Call Fienman Defense at215) 839-9529 for a free, confidential consultation.

Attorney Michael H. Fienman represents individuals and businesses in criminal, white-collar, and fraud-related matters throughout Pennsylvania and New Jersey. He is a dedicated advocate with extensive experience defending clients in state court, federal court, and before administrative and licensing agencies. Attorney Fienman is licensed to practice before the Supreme Court of Pennsylvania, the Supreme Court of New Jersey, the U.S. District Court for the District of New Jersey, and the U.S. District Court for the Eastern District of Pennsylvania.

FAQs About Insurance Fraud