Workers' Compensation on Insurance Antifraud Plans

1. Law
2. Tennessee Code
3. Insurance
4. Workers' Compensation Fraud Act
5. Workers' Compensation on Insurance Antifraud Plans

1. 1. Every insurer shall prepare, implement, maintain and submit to the department of commerce and insurance a workers' compensation insurance anti-fraud plan.
   2. Each insurer's anti-fraud plan shall outline specific procedures to:
      1. Prevent, detect and investigate all forms of insurance fraud, including fraud involving the insurer's employees or agents; fraud resulting from misrepresentations in the application, renewal or rating of insurance policies; claims fraud; and security of the insurer's data processing system;
      2. Educate appropriate employees on fraud detection and the insurer's anti-fraud plan;
      3. Provide for the hiring of or contracting for fraud investigators;
      4. Report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud; and
      5. Pursue restitution for financial loss caused by insurance fraud, where appropriate.
   3. The commissioner may review each insurer's anti-fraud plan to determine if it complies with the requirements of this section.
   4. It is the responsibility of the commissioner to assure insurer compliance with anti-fraud plans submitted to the commissioner. The commissioner may require reasonable modification of the insurer's anti-fraud plan, or may require other reasonable remedial action if the review or examination reveals substantial noncompliance with the terms of the insurer's own anti-fraud plan.
   5. The commissioner may require each insurer to file a summary of the insurer's anti-fraud activities and results. The anti-fraud plans and the summary of the insurer's anti-fraud activities and results are not public records and are exempt from title 10, chapter 7, part 5, and shall be proprietary and not subject to public examination, and shall not be discoverable or admissible in civil litigation.
   6. This section confers no private rights of action.
2. 1. All printed applications for insurance, and all printed claim forms provided and required by an insurer or required by law as a condition of payment of a claim, shall contain a statement, permanently affixed to the application or claim form, that clearly states in substance the following:

      “It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.”

   2. The lack of a statement required in this section does not constitute a defense in any criminal prosecution under § 56-47-103 nor in any civil action under § 56-47-103 or § 56-47-104.
3. Notwithstanding any other provision of title 56, the following are the exclusive monetary penalties for a violation of this section. Insurers that fail to prepare, implement, maintain and submit to the department of commerce and insurance an insurance anti-fraud plan are subject to a penalty of five hundred dollars ($500) per day, not to exceed twenty-five thousand dollars ($25,000).

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