How L and L Law Group defends an insurance fraud case
An insurance fraud accusation is unusual because the evidence already exists before anyone decides to prosecute. We get in front of the carrier's file before it hardens into an indictment and attack the two soft spots every § 35.02 case shares: knowing falsity about something material, and intent to deceive.
An insurance fraud accusation is unusual among criminal charges because the evidence already exists before anyone decides to prosecute. By the time you learn you are a suspect, the carrier's special investigations unit has typically spent months assembling recorded interviews, an examination under oath, scene inspections, and database comparisons — all drawn from your own claim. Our job is to get in front of that file before it hardens into an indictment, and to attack the two soft spots every § 35.02 case shares: whether any statement was knowingly false about something that mattered, and whether the State can prove you meant to deceive rather than merely disagree about a number.
We start by mapping the claim back to its source documents — the proof of loss, the estimates, the invoices, the recorded calls — and separating what you actually said from what a contractor, public adjuster, or billing clerk put in front of you to sign. Then we build the record of the legitimate loss, because Texas law puts that burden on the defense and rewards it directly at sentencing. From there the strategy splits depending on posture: a pre-charge investigation calls for quiet advocacy with the screening prosecutor; a returned indictment calls for a hard look at how the charged "statement" is described and what the discovery file actually shows. Co-founding partners Reggie London and Njeri London handle these matters directly rather than passing them to a screener, and the firm defends claim, application, and provider-kickback cases across the four DFW counties from its single Frisco office. For where this offense sits in the larger fraud landscape, see our white collar and fraud defense overview; for the neutral statutory reference, see the insurance fraud charge encyclopedia entry.
What counts as insurance fraud in Texas?
Texas Penal Code § 35.02 reaches three kinds of conduct: a false statement supporting a claim (subsection (a)), a false statement on a policy application (subsection (a-1)), and the kickback provision (subsection (b)), which needs no false statement at all. The insurer's loss is not an element.
- Claim fraud — § 35.02(a)
- Presenting — or causing someone to present — a statement you know is false or misleading in support of a claim for payment under an insurance policy, with intent to defraud or deceive the insurer. This is the familiar scenario and the most commonly charged subsection.
- Application fraud — § 35.02(a-1)
- Applying the same logic to a policy application rather than a claim. Under § 35.02(d) application fraud is a flat state jail felony regardless of any dollar amount, which is why it is graded separately from the value ladder.
- The kickback provision — § 35.02(b)
- Soliciting, offering, paying, or receiving a benefit in connection with goods or services for which an insurance claim is submitted. This provision needs no false statement at all, and it is how prosecutors charge clinics, chiropractors, body shops, roofers, and case runners inside organized-claim investigations.
- "Statement" — § 35.01(3)
- Any oral or written communication, record, or documented representation of fact made to an insurer — a definition that expressly captures computer-generated information. A recorded call to a claims line, a text to an adjuster, an entry in an online portal, an emailed invoice, and a signed proof-of-loss form are all "statements." Obigbo v. State, 6 S.W.3d 299, 309 (Tex. App.—Dallas 1999, pet. ref'd), confirmed that, where the Legislature has not narrowly defined a term, jurors give it the broadest meaning the context allows.
The companion term "insurance policy" is just as wide under § 35.01(1), sweeping in surety and cash bonds, benefit plans, and motor-club service plans alongside ordinary auto, home, health, and commercial coverage. One feature surprises nearly every client: the insurer's loss is not an element. Nothing in § 35.02 requires that a claim be paid, so a claim that was denied, withdrawn, or still under review when investigators arrived is chargeable on the same footing as one that paid in full. "The company never lost a dollar" is therefore not a defense to guilt — though, used correctly, it is real leverage when we negotiate.
What are the penalties for insurance fraud in Texas?
Punishment tracks the value of the fraudulent claim on the same dollar ladder Texas uses for theft — from a fine-only Class C misdemeanor up to a first-degree felony at $300,000 or more. Three grading rules — the valid-portion offset, the death-or-injury bump, and aggregation — decide more cases than the brackets do.
Punishment tracks the value of the claim on the same dollar ladder Texas uses for theft — a design the appellate courts have traced to deliberate legislative choice. The current brackets, last reset effective September 1, 2015, run from a fine-only misdemeanor to a first-degree felony, as set out in the punishment-range table at the top of this page.
Three grading rules decide more of these cases than the brackets do. The first is that only the fraudulent slice of a claim should set the grade. The Fort Worth Court of Appeals put it plainly: under § 35.02(g), where an accused proves by a preponderance that part of a claim came from a valid covered loss, "the 'value of the claim' is equal to the difference between the total claim amount and the amount of the valid portion of the claim" — in other words, "the 'value of the claim' means the fraudulent portion of the claim." Florez v. State, No. 02-16-00195-CR, slip op. at 3 (Tex. App.—Fort Worth June 8, 2017, no pet.) (mem. op., not designated for publication). A $40,000 hail claim with $3,000 of padding is a state-jail-felony number, not a third-degree number — but only if the legitimate $37,000 is documented and proven. The second rule overrides every dollar figure: under § 35.02(c)(7)(B), any act committed in connection with the offense that places a person at risk of death or serious bodily injury makes the case a first-degree felony no matter how small the claim, which is why staged collisions are charged at the top of the ladder. The third, § 35.03, lets the State combine separate claims made under one scheme — either by aggregating the values or, with three or more claims, bumping the grade one level above the most serious single claim. The two mechanisms are mutually exclusive, so an indictment that stacks both has a defect worth litigating.
Conviction also carries a financial tail most offenses lack. Section 35.02(e) makes restitution to the affected insurer mandatory and expressly includes the carrier's court costs and attorney's fees, and § 35.02(f) allows the same conduct to be prosecuted under Chapter 35, another statute such as theft or arson, or both. For the full sentencing picture across offense levels, our Texas punishment ranges guide lays out each grade in detail.
How the State proves intent — and where it breaks down
For a claim count under § 35.02(a) the State must prove five things beyond a reasonable doubt: a qualifying statement, falsity, materiality under § 35.015, knowledge, and intent to defraud. Intent is the battleground, and it is almost always proven by circumstantial evidence rather than a confession.
For a claim count under § 35.02(a), the State must prove five things beyond a reasonable doubt:
- A qualifying statement
- A communication, record, or documented representation of fact made to an insurer under § 35.01(3). The charge must attach to an identifiable statement — a specific form, recorded interview, invoice, or portal entry. A vague allegation that "the claim was fraudulent" with no pinned-down false statement is exposed.
- Falsity
- Measured against fact, not opinion. A genuine estimate, a value the policyholder believed, or a figure supplied by a third party the policyholder reasonably trusted is not "false" unless the State proves the accused knew otherwise.
- Materiality — § 35.015
- The false information must have been capable of affecting coverage eligibility, the amount payable, or the decision to issue the policy. The Obigbo court added a wrinkle for the State's benefit: the statute's list of examples of "material" information is illustrative, because "the word 'includes' is a term of enlargement and not of limitation." Obigbo, 6 S.W.3d at 308. Even so, a misstatement that could not have moved the payment decision fails the element.
- Knowledge
- The accused must have known the statement was false or misleading when it was made. Honest mistake, faulty memory about a date or serial number, and reliance on someone else's paperwork all attack this element head-on.
- Intent to defraud or deceive
- The highest culpable mental state in the chapter, and the battleground in most contested cases.
Intent is almost never proven by a confession. Texas courts allow it to be inferred from conduct, and the standard is generous to the State: in an insurance fraud appeal the court explained that "the elements of the offense, including intent to defraud and deceive, may be proved by circumstantial evidence" and that a jury "may infer criminal intent from all the circumstances." Obigbo, 6 S.W.3d at 305. Timing, inconsistencies, financial pressure, and what the accused told whom become the proof. That is precisely why the carrier's pre-referral investigation is so dangerous: the special investigations unit gathers recorded interviews, examinations under oath compelled by the policy's cooperation clause, photo metadata, and industry-database comparisons, and by the time the file reaches the Texas Department of Insurance Fraud Unit under Insurance Code Chapter 701, the State's exhibit list is largely your own words. Treat anything you say to an adjuster as a statement to law enforcement, because § 35.01(3) makes it chargeable and Chapter 701 makes it forwardable. The State also gets a statutory head start against providers: under § 35.02(h), a person who submitted a bill in support of a claim is rebuttably presumed to have caused the claim to be presented — a presumption that can be answered, but only with evidence.
Penalty and collateral consequences beyond the sentence
A fraud conviction is a crime of dishonesty, and the paperwork follows you long after any sentence ends — professional-licensing discipline, firearm-rights loss, immigration exposure as a crime involving moral turpitude, mandatory restitution to the insurer, and industry claim databases that outlive the court file.
A fraud conviction is a crime of dishonesty, and the paperwork follows you long after any sentence ends. Licensed insurance agents and adjusters face Texas Department of Insurance discipline independent of the criminal court. Physicians, chiropractors, and nurses pulled into a § 35.02(b) billing case face parallel licensing-board proceedings in which the criminal disposition becomes the central exhibit. A felony conviction strips firearm rights under Penal Code § 46.04 and federal law (18 U.S.C. § 922(g)(1)). For non-citizens, fraud convictions are generally crimes involving moral turpitude, and a fraud offense with a victim loss over $10,000 is an aggravated felony under federal immigration law — among the most serious removal categories that exist. Padilla v. Kentucky, 559 U.S. 356 (2010), requires defense counsel to advise non-citizen clients of these consequences before any plea, and the advice must be specific to the actual offense and the client's actual status.
Add employment screening for banking, bonding, and fiduciary roles, the insurer's civil suit and possible policy rescission, and industry claim databases that outlive the court file, and the cheapest-looking plea can become the most expensive decision in the case. Mapping those consequences — and the expunction or nondisclosure path that may follow a favorable resolution — belongs at the front of the case, not the end. A dismissal or acquittal can support expunction; a deferred-adjudication discharge may support an order of nondisclosure; a final felony conviction forecloses both, which is one more reason the early posture of the case matters so much.
DFW county court practice — where these cases are heard
Insurance fraud is filed in the ordinary criminal courts of the county where the claim conduct occurred — Collin, Dallas, Denton, and Tarrant — and the local docket shapes strategy. We defend these cases in all four counties, plus Rockwall, Kaufman, Ellis, and Hunt, from our single Frisco office.
Insurance fraud is filed and heard in the ordinary criminal courts of the county where the claim conduct occurred, and the local docket shapes strategy.
Collin County
Felony cases are indicted and heard in the district courts at the Collin County Courthouse (the Russell A. Steindam Courts Building) at 2100 Bloomdale Road in McKinney; misdemeanor grades go to the county courts at law in the same building. Collin juries are drawn from Frisco, Plano, McKinney, and Allen — document-literate panels that follow paper trails closely, which rewards a defense built on the client's own records. Many of our Frisco and Plano clients fall in this county.
Dallas County
Dallas County felony dockets run out of the Frank Crowley Courts Building on Riverfront Boulevard, with misdemeanors in the county criminal courts there as well. The county's volume means TDI referrals share space with a heavy violent-crime docket, and intake prosecutors retain discretion — so a well-documented presentation before indictment can influence whether a borderline file is charged as filed, reduced, or declined. See our Dallas criminal defense page.
Denton County
Cases file at the Denton County Courts Building in Denton. The county's suburban property-claim mix — roofs, vehicles, water losses — makes contractor-driven supplements a recurring fact pattern, which puts the knowledge element front and center. See our Denton County page.
Tarrant County
Fort Worth's Tim Curry Criminal Justice Center houses both the felony district courts and the misdemeanor courts. As elsewhere, restitution posture matters early: arriving at the first setting with a concrete accounting of the legitimate loss changes the tone of the conversation. See our Fort Worth page.
We defend insurance fraud cases in all four counties — and in Rockwall, Kaufman, Ellis, and Hunt — from our single office at 5899 Preston Road, Suite 101, in Frisco. We do not maintain branch offices in Dallas, Fort Worth, or Denton; we appear in those courts and defend those cases from Frisco. Once a case is filed, magistration under Code of Criminal Procedure article 15.17 brings the bail decision within roughly 48 hours, felony grades go to a grand jury for indictment, and discovery under article 39.14 reaches the entire claim file, the unit workup, and the referral packet — meaning the defense gets to audit the investigation that built the case. Our guide to fighting a charge and our bond conditions overview walk through each stage in plain English.
Key legal terms
Five terms decide most insurance fraud cases: the offense itself under § 35.02, the broad "statement" definition under § 35.01(3), materiality under § 35.015, the value-of-the-claim offset under § 35.02(g), and the provider presumption under § 35.02(h).
- Insurance Fraud — § 35.02
- Knowingly presenting a false or misleading material statement to an insurer with intent to defraud, in support of a claim or application — or, under subsection (b), paying or receiving a benefit tied to goods or services billed to an insurer.
- Statement — § 35.01(3)
- Any oral or written communication, record, or documented representation of fact made to an insurer — expressly including computer-generated information such as portal entries and recorded calls.
- Materiality — § 35.015
- A false statement is material if it could have affected coverage eligibility, the amount payable, or the decision to issue the policy. The test is objective and possibility-based.
- Value of the Claim — § 35.02(g)
- The figure that sets the punishment grade. Where the accused proves a valid covered loss by a preponderance, the value drops to the fraudulent portion only — the total claim minus the legitimate part.
- Provider Presumption — § 35.02(h)
- A rebuttable presumption that a person who submitted a bill in support of a claim caused that claim to be prepared or presented — aimed at providers who later blame a billing department.
These five terms recur in nearly every § 35.02 case, and each is a place where a careful defense can change the outcome — by pinning the State to a specific statement, by testing whether the misstatement was truly material, by documenting the legitimate portion of the loss, or by answering the provider presumption with evidence. For a wider vocabulary of Texas criminal-law terms, see our legal glossary.
