Jurisdiction
noSun4Me
An individual has a medical provider bill his health insurance company
for a service to another person, but under his name. I assume this is
insurance fraud, the question is, if the insurance provider is in
another state, where has the fraud occurred, and which state has
jurisdiction over the crime?
grendal
Where did the fraud take place?
You have two potential hypothetical crimes.
Someone stole the id and used it to get service. Or the clinic
committed fraud.
Either case, the fraud was committed where the clinic exists so that
would be the jurisdiction.
Unfortunately, not too hypothetical. There was a 60 minutes expose on
this recently.
Seth
X is in NY. Y gets medical service in NJ; X sends the bill to his
insurer in CT to pay it (lying about for whom the service was
performed).
If the fraud occurred in NJ, then how can X get prosecuted? X was
never in NJ, and doesn't go there. X performed the action that
constituted fraud in NY, and victimized a company in CT.
In a civil case for damages, X can certainly be sued in NY and maybe
CT. I don't see how X could be sued in NJ.
Seth
Robert Bonomi
Simple question, right? Well not all that simple ...
The individual is almost certainly covered under a policy issued in the state
where he lives. (States _do_ tend to limit 'who' can sell insurance policies
of any sort to their residents -- and generally require that the 'issuer' have
a legal presence _in_ the state, should any of various 'enforcement' practices
become necessary, up to and including the 'seizure' of the insurer.) The fraud
occurs wherever it was that the medical provider submitted the information to
the insurer. This may or may not be the state where:
(a) the treatment occurred, (b) the insured (and, most probably, the insurer as
well) resides, or (c) where the insurer's 'claims processing offices' are.
There -may- be Federal issues involved as well -- e.g., see 18 USC 669 (a).
Also, possible mail fraud, and/or wire fraud, depending on how the information
was transmitted to the insurer.
In addition, *If* the named insured provided 'consideration' to the provider
for their 'false' action, then there is a possible 'conspiracy' element, as
well.
Jurisdiction for the conspiracy charge(s) is wherever the parties were _when_
the agreement for the consideration occurred; _with_ possible additional
jurisdiction(s) dependent on where the parties were when the consideration
changed hands.
Barry Gold
fraud]
Seth <se...@panix.com> wrote:
>X is in NY. Y gets medical service in NJ; X sends the bill to his
>insurer in CT to pay it (lying about for whom the service was
>performed).
>
>If the fraud occurred in NJ, then how can X get prosecuted? X was
>never in NJ, and doesn't go there. X performed the action that
>constituted fraud in NY, and victimized a company in CT.
Fraud is also a crime. NJ can indict X for making a false insurance
claim, and apply to NY for extradition. Once X is extradited to NJ,
he can _also_ be sued civilly in NJ (AFAIK).
>In a civil case for damages, X can certainly be sued in NY and maybe
>CT. I don't see how X could be sued in NJ.
If X was complicit in the fraud (which occurred in NJ), then it is
quite possible that a NJ court will decide that he had the requisite
involvement with NJ and allow him to be sued there. The complaint
will have to be physically served to X in NY, of course.
--
Barry Gold, webmaster:
Conchord: http://www.conchord.org
Los Angeles Science Fantasy Society, Inc.: http://www.lasfsinc.org
Cy Pres
wrote:
>X is in NY. Y gets medical service in NJ; X sends the bill to his
>insurer in CT to pay it (lying about for whom the service was
>performed).
Why did X do this? Did X know that Y was going to do this beforehand?
Did they agree to do this beforehand? If so, that's a conspiracy,
part of the effects of which and the operative facts of which occurred
in New Jersey.
After all, it was in New Jersey where Y made the materially false
misleading statement upon which the insurer relied in paying for it.
>If the fraud occurred in NJ, then how can X get prosecuted? X was
>never in NJ, and doesn't go there. X performed the action that
>constituted fraud in NY, and victimized a company in CT.
In Internet crimes, often the perpetrator has never "been" to the
locus of the offense, either. Further, in defamation cases, the
defendant has often never "been" to the home state of the plaintiff,
but if it can be shown that the defendant intentionally directed the
consequences of his actions at the forum state, there might be
jurisdiction.
>In a civil case for damages, X can certainly be sued in NY and maybe
>CT. I don't see how X could be sued in NJ.
I think that if Y went to get medical service in NJ as part of a
conspiracy with X, X could be prosecuted in NJ just as well as Y could
be. Depending on the facts, venue might be improper, though, and I
suppose there might be some court out there that wouldn't find
jurisdiction.
It might be different if, somehow, Y gets medical service, doesn't
know anything about X, and X after the fact somehow intercepts the
transaction and swindles the insurance company, tricking them into
reimbursing X directly for Y's medical treatment.
Seth
>[Concerning which state has jurisdiction over medical insurance
>fraud]
> Seth <se...@panix.com> wrote:
>>X is in NY. Y gets medical service in NJ; X sends the bill to his
>>insurer in CT to pay it (lying about for whom the service was
>>performed).
>>
>>If the fraud occurred in NJ, then how can X get prosecuted? X was
>>never in NJ, and doesn't go there. X performed the action that
>>constituted fraud in NY, and victimized a company in CT.
>
>Fraud is also a crime.
I never disagreed with that.
> NJ can indict X for making a false insurance claim,
Why? X made a false claim from NY, to a company in CT. What does NJ
have to do with anything?
>>In a civil case for damages, X can certainly be sued in NY and maybe
>>CT. I don't see how X could be sued in NJ.
>
>If X was complicit in the fraud (which occurred in NJ),
How did the fraud occur in NJ?
Changing the facts a little: Y got treated in NJ, and paid the bill in
full, in cash. X got a copy of the bill, changed the name on it, and
sent it to X's insurance company in CT, requesting that X be
reimbursed. (I used to have a dentist that worked that way: I paid
him at time of service, he'd fill out the insurance form and they'd
mail me a check.)
> then it is quite possible that a NJ court will decide that he had
>the requisite involvement with NJ and allow him to be sued there.
How did X have any involvement with NJ?
Seth
John F. Carr
Robert Bonomi <bon...@host122.r-bonomi.com> wrote:
>There -may- be Federal issues involved as well -- e.g., see 18 USC 669 (a).
>Also, possible mail fraud, and/or wire fraud, depending on how the information
>was transmitted to the insurer.
I would say mail fraud is almost inevitable in the course of insurance
fraud. One does not need to send mail to commit mail fraud. Forseeable
use of the mail by another person is sufficient, e.g. if an insurance
company mails you a check to pay a fraudulent claim.
--
John Carr (j...@mit.edu)
Seth
Cy Pres <c.p...@yahoo.com> wrote:
>On Mon, 23 Nov 2009 20:47:30 +0000 (UTC), se...@panix.com (Seth)
>wrote:
>
>>X is in NY. Y gets medical service in NJ; X sends the bill to his
>>insurer in CT to pay it (lying about for whom the service was
>>performed).
>
>Why did X do this? Did X know that Y was going to do this beforehand?
>Did they agree to do this beforehand? If so, that's a conspiracy,
>part of the effects of which and the operative facts of which occurred
>in New Jersey.
OK, so let's assume that X didn't know anything beforehand. Y visited
X, and complained about the high cost of treatment. X offered to try
to get his insurance company to pay for it, so Y handed X the bill
which X modified and submitted.
>After all, it was in New Jersey where Y made the materially false
>misleading statement upon which the insurer relied in paying for it.
Y made no false or misleading statement in NJ.
>>If the fraud occurred in NJ, then how can X get prosecuted? X was
>>never in NJ, and doesn't go there. X performed the action that
>>constituted fraud in NY, and victimized a company in CT.
>
>In Internet crimes, often the perpetrator has never "been" to the
>locus of the offense, either.
That's why I specified that CT was also a possible venue; CT is the
location of the victim, where the crime took effect.
> Further, in defamation cases, the defendant has often never "been"
>to the home state of the plaintiff, but if it can be shown that the
>defendant intentionally directed the consequences of his actions at
>the forum state, there might be jurisdiction.
X directed the consequences of his actions at CT.
>It might be different if, somehow, Y gets medical service, doesn't
>know anything about X, and X after the fact somehow intercepts the
>transaction and swindles the insurance company, tricking them into
>reimbursing X directly for Y's medical treatment.
Sure; that's a simpler case, just X committing fraud. What about my
example above, where Y and X were friends, but the idea for the fraud
didn't arise until after the treatment was performed (and paid for)?
Seth
Mike
>
> Changing the facts a little: Y got treated in NJ, and paid the bill in
> full, in cash. X got a copy of the bill, changed the name on it, and
> sent it to X's insurance company in CT, requesting that X be
> reimbursed. (I used to have a dentist that worked that way: I paid
> him at time of service, he'd fill out the insurance form and they'd
> mail me a check.)
>
Then it would seem X committed the fraud in NY and could be prosecuted
there, even though the services themselves were provided in NJ.
Cy Pres
wrote:
>OK, so let's assume that X didn't know anything beforehand. Y visited
>X, and complained about the high cost of treatment. X offered to try
>to get his insurance company to pay for it, so Y handed X the bill
>which X modified and submitted.
Okay, but this is the opposite of my hypothetical.
>>After all, it was in New Jersey where Y made the materially false
>>misleading statement upon which the insurer relied in paying for it.
>Y made no false or misleading statement in NJ.
In the case of X actually conspiring with Y, though, X is a party to
all the actions of co-conspirators taken pursuant to the conspiracy. I
agree that
>>In Internet crimes, often the perpetrator has never "been" to the
>>locus of the offense, either.
>That's why I specified that CT was also a possible venue; CT is the
>location of the victim, where the crime took effect.
There were also effects of the crime in New Jersey, though, in either
the conspiracy or non-conspiracy case. For example, perhaps the
providers of the medical service would be required to return the
compensation they received for services they provided in good faith,
thus depriving them of the money. Due to X's actions, they got duped
into providing medical services for which they receive no
compensation.
Therefore, they would be victims, too. Even if their victimhood is
limited to having to waste more time answering questions from police,
fraud investigators, lawyers, etc., there may be enough effects in NJ
to maintain jurisdiction.
As I said in my original post, though, the claim for jurisdiction is
much weaker where X wasn't a party to Y's statement in NJ.
>> Further, in defamation cases, the defendant has often never "been"
>>to the home state of the plaintiff, but if it can be shown that the
>>defendant intentionally directed the consequences of his actions at
>>the forum state, there might be jurisdiction.
>X directed the consequences of his actions at CT.
X was also entirely aware of the potential consequences to the medical
providers in NJ. They were reasonably foreseeable. In fact, to base
his fraud on a transaction in NJ, it is very likely he somehow
accessed electronic or other records residing in NJ.
Regardless, he was aware the transaction was in NJ, and based his
crime on that knowledge. If there are effects of any sort in NJ,
there is at least an argument for jurisdiction there, though it gets
weaker as the effects get weaker.
>>It might be different if, somehow, Y gets medical service, doesn't
>>know anything about X, and X after the fact somehow intercepts the
>>transaction and swindles the insurance company, tricking them into
>>reimbursing X directly for Y's medical treatment.
>Sure; that's a simpler case, just X committing fraud. What about my
>example above, where Y and X were friends, but the idea for the fraud
>didn't arise until after the treatment was performed (and paid for)?
The mechanics of this bother me, though. How does someone get medical
services like this, when medical providers generally insist on some
form of identification or proof of insurance up front? It would seem
this kind of fraud would usually if not always involve conspiracy of
some sort between the perpetrators.
Often, prosecutors are going to bring an action wherever it is most
convenient for *them*, if they have a reasonable (or sometimes even
patently flimsy) argument for jurisdiction. After all, if they lose
the jurisdiction argument, they can always bring the case somewhere
else, and the defendant is already out a good chunk of her defense
budget.
grendal
> X is in NY. �Y gets medical service in NJ; X sends the bill to his
> insurer in CT to pay it (lying about for whom the service was
> performed).
>
> If the fraud occurred in NJ, then how can X get prosecuted? �X was
> never in NJ, and doesn't go there. �X performed the action that
> constituted fraud in NY, and victimized a company in CT.
>
> In a civil case for damages, X can certainly be sued in NY and maybe
> CT. �I don't see how X could be sued in NJ.
>
> Seth
You have a couple of frauds here.
X could be sued in NJ because X was complicit of committing the
initial fraud.
X and Y could be sued in NY because that was where X submitted the
false documentation for service that Y received, even though Y never
stepped foot in NY.
They could both be sued in CT because the fraud took place against the
insurance provider. So whichever court will yield a favorable judgment
against X and Y and potentially the doctor as well.
This is one type of insurance fraud.
The other is where X had nothing to do with the fraud and Y stole X's
identity to get medical treatment. Then Y and the doctor could
possibly be at risk for criminal prosecution.
Meaning that the doctor was in on the scam to begin with.
Or it could be that there never was a Y and that the doctor was
bilking the insurance company out of money by using stolen identities
to bill for services never performed.
Sort of like a medical supply shop that bills the insurance companies
for medical equipment that they claim to have sold, yet there is no
warehouse nor any shipments of the medical supplies ever made.
grendal
> How did X have any involvement with NJ?
>
> Seth
That was where Y went for medical treatment. (Hypothetically of
course)
So if the 'treatment' took place in NJ, X can get hauled in to court.
Seth
Cy Pres <c.p...@yahoo.com> wrote:
>On Wed, 25 Nov 2009 20:55:38 +0000 (UTC), se...@panix.com (Seth)
>wrote:
>
>>OK, so let's assume that X didn't know anything beforehand. Y visited
>>X, and complained about the high cost of treatment. X offered to try
>>to get his insurance company to pay for it, so Y handed X the bill
>>which X modified and submitted.
>
>Okay, but this is the opposite of my hypothetical.
>
>>>After all, it was in New Jersey where Y made the materially false
>>>misleading statement upon which the insurer relied in paying for it.
>
>>Y made no false or misleading statement in NJ.
>
>In the case of X actually conspiring with Y, though, X is a party to
>all the actions of co-conspirators taken pursuant to the conspiracy. I
>agree that
The conspiracy didn't happen until after Y had the treatment in NJ,
paid cash for it, and left NJ, meeting X in NY.
>There were also effects of the crime in New Jersey, though, in either
>the conspiracy or non-conspiracy case. For example, perhaps the
>providers of the medical service would be required to return the
>compensation they received for services they provided in good faith,
They got paid in cash by Y, who received the treatment. To whom would
they be required to *return* the payment? Why?
>>X directed the consequences of his actions at CT.
>
>X was also entirely aware of the potential consequences to the medical
>providers in NJ.
What consequences? The provider in NJ was paid cash by Y and is out
of it.
> They were reasonably foreseeable. In fact, to base
>his fraud on a transaction in NJ, it is very likely he somehow
>accessed electronic or other records residing in NJ.
No, he used a paper copy of the bill provided to Y.
>Regardless, he was aware the transaction was in NJ, and based his
>crime on that knowledge. If there are effects of any sort in NJ,
>there is at least an argument for jurisdiction there, though it gets
>weaker as the effects get weaker.
In my hypothetical, there are no such effects.
>>Sure; that's a simpler case, just X committing fraud. What about my
>>example above, where Y and X were friends, but the idea for the fraud
>>didn't arise until after the treatment was performed (and paid for)?
>
>The mechanics of this bother me, though. How does someone get medical
>services like this, when medical providers generally insist on some
>form of identification or proof of insurance up front?
Y paid cash. Y provided identity documents, identifying him as Y.
> It would seem this kind of fraud would usually if not always
>involve conspiracy of some sort between the perpetrators.
After Y and X met, they conspired, and altered the documents Y already
had.
Seth
Seth
grendal <im_g...@hotmail.com> wrote:
>On Nov 25, 2:51�pm, se...@panix.com (Seth) wrote:
>
>> How did X have any involvement with NJ?
>That was where Y went for medical treatment. (Hypothetically of
>course)
Right. Y went to NJ for medical treatment. X knew nothing about
that. Subsequently, Y met X in NY and X attempted to defraud a
company in CT.
>So if the 'treatment' took place in NJ, X can get hauled in to court.
Based on what? Y paid cash for the treatment in NJ, so nobody in NJ
was harmed in any way. X didn't do anything that affects anybody in
NJ.
Seth
Seth
grendal <im_g...@hotmail.com> wrote:
>On Nov 23, 2:47�pm, se...@panix.com (Seth) wrote:
>
>> X is in NY. �Y gets medical service in NJ; X sends the bill to his
>> insurer in CT to pay it (lying about for whom the service was
>> performed).
>>
>> If the fraud occurred in NJ, then how can X get prosecuted? �X was
>> never in NJ, and doesn't go there. �X performed the action that
>> constituted fraud in NY, and victimized a company in CT.
>>
>> In a civil case for damages, X can certainly be sued in NY and maybe
>> CT. �I don't see how X could be sued in NJ.
>
>X could be sued in NJ because X was complicit of committing the
>initial fraud.
There is only one fraud: X (and Y) submitting a false bill to X's
insurance company. What do you mean by "initial fraud"?
>X and Y could be sued in NY because that was where X submitted the
>false documentation for service that Y received, even though Y never
>stepped foot in NY.
Agreed. (Even though I specified that Y entered NY where he conspired
with X.)
>They could both be sued in CT because the fraud took place against the
>insurance provider.
Agreed.
> So whichever court will yield a favorable judgment
>against X and Y and potentially the doctor as well.
Why the doctor? He performed a service for Y, got paid, and gave Y a
bill (receipt).
Seth