ENGROSSED

COMMITTEE SUBSTITUTE

FOR

H. B. 4310

(By Delegates Phillips and Michael)


(Originating in the House Committee

on Banking and Insurance)


[February 23, 1994]


A BILL to amend and reenact section four, article twenty-four, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended; to amend and reenact section six, article twenty-five of said chapter; to amend and reenact section twenty-four, article twenty-five-a of said chapter; to amend chapter thirty-three of said code by adding thereto a new article, designated article forty; and to amend chapter sixty-one of said code by adding thereto a new article, designated article five-b, all relating to insurance fraud; subjecting certain hospital, medical, dental and health service corporations, health care corporations and health maintenance organizations to insurance fraud provisions; defining terms; establishing an insurance fraud unit within the division of insurance; requiring the promulgation of rules and filing of annual reports; establishing powers and duties; outlining investigative powers and procedures; providing confidentiality and immunity; prohibiting insurance fraud; establishing penalties and fines; authorizing prosecution for fraudulent acts; authorizing special prosecutors; specifying duties of insurers; authorizing the special appropriation of funds; establishing the West Virginia Insurance Fraud Prevention Act; defining legislative intent and terms; creating misdemeanor and felony offenses for the commission of fraudulent acts; and creating penalties, exceptions and immunities.
Be it enacted by the Legislature of West Virginia:

That section four, article twenty-four, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended and reenacted; that section six, article twenty-five and section twenty-four, article twenty-five-a of said chapter be amended and reenacted; that chapter thirty-three be amended by adding thereto a new article, designated article forty; and that chapter sixty-one be amended by adding thereto a new article, designated article five-b, all to read as follows:
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE CORPORATIONS.

§ 33-24-4. Exemptions; applicability of insurance laws.

Every corporation defined in section two of this article is hereby declared to be a scientific, nonprofit institution and exempt from the payment of all property and other taxes. Every corporation, to the same extent the provisions are applicable to insurers transacting similar kinds of insurance and not inconsistent with the provisions of this article, shall be governed by and be subject to the provisions as hereinbelow indicated, of the following articles of this chapter: Article two (insurance commissioner), except that, under section nine of said article, examinations shall be conducted at least once every four years; article four (general provisions), except that section sixteen of said article shall not be applicable thereto; article six, section thirty-four (fee for form and rate filing); article six-c (guaranteed loss ratio); article seven (assets and liabilities); article eleven (unfair trade practices); article twelve (agents, brokers and solicitors), except that the agent's license fee shall be five dollars; section fourteen, article fifteen (individual accident and sickness insurance); article fifteen-a (long-term care insurance); section three, article sixteen (required policy provisions); section three-a, article sixteen (mental illness); section three-c, article sixteen (group accident and sickness insurance); section three-d, article sixteen (medicare supplement insurance); section three-f, article sixteen (treatment of temporomandibular joint disorder and craniomandibular disorder); article sixteen-a (group health insurance conversion); article sixteen-c (small employer group policies); article sixteen-d (marketing and rate practices for small employers); article twenty-six-a (West Virginia life and health insurance guaranty association act), after the first day of October, one thousand nine hundred ninety-one; article twenty-seven (insurance holding company systems); article twenty-eight (individual accident and sickness insurance minimum standards); article thirty-three (annual audited financial report); article thirty-four (administrative supervision); article thirty-four-a (standards and commissioner's authority for companies deemed to be in hazardous financial condition); article thirty-five (criminal sanctions for failure to report impairment); and article thirty-seven (managing general agents); and article forty (insurance fraud unit), and no other provision of this chapter may apply to these corporations unless specifically made applicable by the provisions of this article. If, however, the corporation is converted into a corporation organized for a pecuniary profit or if it transacts business without having obtained a license as required by section five of this article, it shall thereupon forfeit its right to these exemptions.
 ARTICLE 25. HEALTH CARE CORPORATIONS.
§ 33-25-6. Supervision and regulation by insurance commissioner; exemption from insurance laws.

Corporations organized under this article are subject to supervision and regulation of the insurance commissioner. The corporations organized under this article, to the same extent these provisions are applicable to insurers transacting similar kinds of insurance and not inconsistent with the provisions of this article, shall be governed by and be subject to the provisions as hereinbelow indicated, of the following articles of this chapter: Article four (general provisions), except that section sixteen of said article shall not be applicable thereto; article six-c (guaranteed loss ratio); article seven (assets and liabilities); article eight (investments); article ten (rehabilitation and liquidation); section fourteen, article fifteen (individual accident and sickness insurance); section three, article sixteen (required policy provisions); article sixteen-a (group health insurance conversion); article sixteen-c (small employer group policies); article sixteen-d (marketing and rate practices for small employers); article twenty-six-a (West Virginia life and health insurance guaranty association act); article twenty-seven (insurance holding company systems); article thirty-three (annual audited financial report); article thirty-four-a (standards and commissioner's authority for companies deemed to be in hazardous financial condition); article thirty-five (criminal sanctions for failure to report impairment); and article thirty-seven (managing general agents); and article forty (insurance fraud unit); and no other provision of this chapter may apply to these corporations unless specifically made applicable by the provisions of this article.

 ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§ 33-25A-24. Statutory construction and relationship to other laws.

(a) Except as otherwise provided in this article, provisions of the insurance laws and provisions of hospital or medical service corporation laws shall not be applicable to any health maintenance organization granted a certificate of authority under this article. This provision shall not apply to an insurer or hospital or medical service corporation licensed and regulated pursuant to the insurance laws or the hospital or medical service corporation laws of this state except with respect to its health maintenance corporation activities authorized and regulated pursuant to this article.

(b) Factually accurate advertising or solicitation regarding the range of services provided, the premiums and copayments charged, the sites of services and hours of operation, and any other quantifiable, nonprofessional aspects of its operation by a health maintenance organization granted a certificate of authority, or its representative shall not be construed to violate any provision of law relating to solicitation or advertising by health professions: Provided, That nothing contained herein shall be construed as authorizing any solicitation or advertising which identifies or refers to any individual provider, or makes any qualitative judgment concerning any provider.
(c) Any health maintenance organization authorized under this article shall not be deemed to be practicing medicine and shall be exempt from the provision of chapter thirty of this code, relating to the practice of medicine.
(d) The provisions of section fifteen, article four (general provisions), article six-c (guaranteed loss ratio), article seven (assets and liabilities), article eight (investments), section fourteen, article fifteen (individual accident and sickness insurance), article fifteen-b (uniform health care administration act); section three, article sixteen (required policy provisions); section three-f, article sixteen (treatment of temporomandibular disorder and craniomandibular disorder), article sixteen-a (group health insurance conversion), article sixteen-c (small employer group policies), article sixteen-d (marketing and rate practices for small employers), article twenty-seven (insurance holding company systems), article thirty-four-a (standards and commissioner's authority for companies deemed to be in hazardous financial condition), article thirty-five (criminal sanctions for failure to report impairment); and article thirty-seven (managing general agents); and article forty (insurance fraud unit), shall be applicable to any health maintenance organization granted a certificate of authority under this article.
(e) Any long-term care insurance policy delivered or issued for delivery in this state by a health maintenance organization shall comply with the provisions of article fifteen-a of this chapter.
CHAPTER 33. INSURANCE

 ARTICLE 40. INSURANCE FRAUD UNIT.
§ 33-40-1. Legislative purpose and findings; powers and duties of fraud control unit.

(a) It is the finding of the Legislature that substantial sums of money have been lost to the insurance industry and, ultimately, to the consumers of this state, due to the overpayment of moneys to persons who submit false or fraudulent insurance claims. It is the purpose of the Legislature to establish an insurance fraud unit within the West Virginia division of insurance and to provide it with the responsibility and authority for detecting, investigating and controlling insurance fraud and abuse within this state and reducing costs to both insurers and consumers.

 § 33-40-2. Definitions.
The following words when used in this article have the meanings ascribed to them in this section, except in those instances where the context clearly indicates a different meaning:
(a) "Authorized agency" means:
(1) The division of public safety of this state, the police department of any municipality, any county sheriff's department, and any duly constituted criminal investigative department or agency of the United States or of this state;
(2) The prosecuting attorney of any county of this state or of the United States or any district thereof; or
(3) The state insurance commissioner.
(b) "Benefits" means money payments, goods, services, or any other thing of value.
(c) "Claim" means an application for payment for goods or services provided under any insurance policy issued to any person in this state.
(d) "Commissioner" means the insurance commissioner of the state of West Virginia.
(e) "Director" means the director of the insurance fraud unit established pursuant to this article.
(f) "Financial loss" includes, but is not limited to, loss of earnings, out of pocket and other expenses, repair and replacements costs and claims payments made by any insurer, provider or person.
(g) "Health care provider" means any person, firm or corporation rendering health care services within this state.
(h) "Insured" means any person, as defined herein, who is entitled to insurance coverage, benefits or protection pursuant to a policy of insurance issued by any insurer, including, but not limited to, the policyholder, family members included as insureds or beneficiaries and any person entitled to health, property or liability coverage pursuant to the terms of such policy.
(i) "Insurer" means any person, firm or corporation which issues to any person in this state any policy of insurance as defined by section ten, article one, of this chapter; a hospital service corporation, medical service corporation or health service corporation organized pursuant to article twenty-four of this chapter; a health care corporation organized pursuant to article twenty-five of this chapter; or a health maintenance organization organized pursuant to article twenty-five-a of this chapter.
(j) "Insurance representative" means any person, firm or corporation acting on an insurer's behalf, including, but not limited to any agent, adjuster, officer, director, employee or investigator.
(k) "Person" means any individual, partnership, firm, association, corporation, company, insurer, organization, society, reciprocal, business trust or any other legal entity. "Person" also includes hospital service corporations, medical service corporations and dental service corporations as defined in article twenty-four of this chapter, health care corporations as defined in article twenty-five of this chapter, or a health maintenance organization organized pursuant to article twenty-five-a of this chapter.
(l) "Statement" means any written or oral representation made to any person, insurer or authorized agency. A statement includes, but is not limited to, any oral report or representation; any insurance application, policy, notice or statement; any proof of loss, bill of lading, receipt for payment, invoice, account, estimate of property damages, or other evidence of loss, injury or expense; any bill for services, diagnosis, prescription, hospital or doctor record, x-ray, test result or other evidence of treatment, services or expense; and any application, report, actuarial study, rate request or other such document submitted or required to be submitted to any authorized agency.
(m) "Unit" means the insurance fraud unit established pursuant to the provisions of this article and any person or representative authorized to act on behalf of the same.
§ 33-40-3. Insurance fraud unit established; director to be appointed; office space and staff provisions; promulgation of rules; annual report.

(a) There is hereby established an insurance fraud unit within the division of insurance. The commissioner shall appoint a full time director of the insurance fraud unit and the chief investigator. The director and the chief investigator shall serve at the pleasure of the commissioner and shall be qualified by training and experience to perform the duties of their positions. The commissioner shall provide the clerical and other staff necessary for the unit to fulfill its responsibilities under this article.

(b) The insurance commissioner shall provide office space, hearing rooms, equipment and supplies for the insurance fraud unit and its staff.
(c) The commissioner may promulgate rules pursuant to article three, chapter twenty-nine-a of this code in order to effect the purposes of this article.
(d) On or before the first day of each regular session of the Legislature, the commissioner shall file with the governor, the clerk of the Senate and the clerk of the House of Delegates a report detailing the actions taken by the insurance fraud unit in the preceding fiscal year.
 § 33-39-4. Powers and duties.
(a) The insurance fraud unit created pursuant to this article shall have the following powers and duties:
(1) To employ and train personnel to achieve the purposes of this article and to employ legal counsel, investigators, auditors and clerical support personnel and such other personnel as the commissioner deems necessary from time to time to accomplish the purposes herein;
(2) To initiate independent inquiries and conduct independent investigations when the director has cause to believe that an act of insurance fraud has been, or is currently being committed;
(3) To review reports or complaints of alleged insurance fraud from federal, state and local police, other law enforcement authorities, governmental agencies or units, insurers, and the general public; determine whether such reports require further investigation; and conduct such investigations;
(4) To administer oaths or affirmations;
(5) To issue subpoenas for witnesses and documents relevant to an investigation, including information concerning the existence, description, nature, custody, condition and location of any book, record, documents or other tangible thing and the identity and location of persons having knowledge of relevant facts or any matter reasonably calculated to lead to the discovery of admissible evidence;
(6) To refer for prosecution all violations of applicable state and federal laws pertaining to the provision of insurance benefits to any person, firm or corporation;
(7) To cooperate with federal or state government officials and insurers to investigate, detect, deter and prosecute fraud and abuse in the insurance industry of the state; and
(8) To communicate and exchange data and information with federal or state agencies, divisions, departments or officers and with health care providers, insurers or other interested parties regarding insurance fraud issues.
(b) The insurance fraud unit is further empowered to perform such other duties as may be necessary to effect the purposes of the unit or as may be prescribed by the insurance commissioner.
 § 33-40-5. Investigations; procedures; subpoena powers.
(a) When the unit has probable cause to believe that a person has engaged in an act or activity which is subject to prosecution under this article, the unit shall make an investigation to determine if the act has been committed and report the findings of such investigation to the director.
(b) If the unit seeks evidence, documentation or related materials located within this state pertinent to an investigation or examination, the unit may by request or subpoena gain access to the material. Such material shall be made available to the unit or shall be made available for inspection or examination by a designated representative of the unit.
(c) If documents necessary to an investigation of the unit shall appear to be located outside the state, such documents shall be made available by the person or entity within the jurisdiction of the state having control over such documents either at a convenient location within the state or, upon payment of reasonable and necessary expenses to the unit for transportation and inspection, at the place outside the state where such documents are maintained.
(d) Upon failure of a person to comply with a subpoena or subpoena duces tecum or failure of a person to give testimony without lawful excuse and upon reasonable notice to all persons affected thereby, the unit may apply to the circuit court of the county in which compliance is sought for appropriate orders to compel obedience with the provisions of this section.
 § 33-40-6. Confidentiality and immunity from subpoena.
(a) The unit shall not make public the name or identity of a person whose acts or conduct is investigated pursuant to this section or the facts disclosed in such investigation except as the same may be used in any legal action or enforcement proceeding brought pursuant to this article or any other provision of this code.
(b) All papers, records, documents, reports, materials or other evidence relevant to an insurance fraud investigation or examination shall remain confidential and shall not be subject to public inspection so long as the director deems it is reasonably necessary to protect the privacy of the person or matter investigated or examined, to protect the person furnishing the material, or to be in the public interest.
(c) Such papers, records, documents, reports,materials or other evidence relevant to an insurance fraud investigation or examination shall not be subject to subpoena until opened for public inspection by the director.
 § 33-40-7. Insurance fraud.
(a) It is a fraudulent insurance act for any person, with the intent to injure, defraud or deceive any person or insurer, to present or cause to be presented to any insurer or insurance representative, any written statement as part of or in support of an application for insurance or a claim for payment or other benefit pursuant to an insurance policy, knowing that such statement contains any false, incomplete or misleading information concerning any fact or thing material to the application, claim or benefit.
(b) It is a fraudulent insurance act for any person, with the intent to injure, defraud or deceive any person or insurer, to assist, abet, solicit or conspire with another to prepare or make any written statement that is intended to be presented to any insurer in connection with or in support of any application for insurance or any claim for payment or other benefit pursuant to an insurance policy, knowing that such statement contains any false, incomplete or misleading information concerning any fact or thing material to the application, claim or benefit.
(c) It is a fraudulent insurance act for any insurer or insurance representative, with the intent to injure, defraud or deceive any person or authorized agency, to submit or cause to be submitted to any authorized government agency, any written or oral statement as part of or in support of any application, audit, report, valuation, statement, appraisal, estimation of loss, publication, certificate, actuarial report or study, filing, financial statement, tax return, rate request, petition or any other such document knowing that such statement contains any false, incomplete or misleading information concerning any fact or thing material to the application, report or other such document being submitted.
(d) It is a fraudulent act for any insurer or insurance representative, with the intent to injure, defraud or deceive any person or authorized agency, to present or submit, or cause to be presented or submitted, to any person or authorized agency any written or oral statement in connection with any insurance application, claim or other benefit, knowing that such statement contains any false, incomplete or misleading information regarding any fact or thing material to the application, claim or benefit.
(e) It is a fraudulent act for any person to solicit, offer or receive any remuneration, including any kickback, rebate or bribe, directly or indirectly, with the intent of causing an expenditure of moneys from any person or insurer which would not otherwise be payable under the applicable policy.
(f) Any person found to be in violation of the provisions of this section is guilty of a felony or misdemeanor, as determined by the provisions of sections four and five, article five-b, chapter sixty-one of this code, and, upon conviction thereof, shall be fined, imprisoned or both, as more particularly provided in said sections. In addition to any fine or imprisonment, any person found to be in violation of the provisions of this section shall be required to make full restitution to the person injured or damaged by the fraudulent act in a manner to be determined by the court.
§ 33-40-8. Prosecution for fraudulent acts; special prosecutors; director's report to the commissioner.

(a) If, upon review of any report submitted by the unit, the director determines that probable cause exists to suspect that an act of insurance fraud has been committed, the director shall present any evidence of alleged insurance fraud to the prosecutor in the jurisdiction where the alleged acts of insurance fraud took place and request appropriate criminal prosecution.

(b) Upon receipt of the report and request from the director, the prosecutor may, where deemed appropriate, criminally prosecute any person for insurance fraud.
(c) Upon application of the prosecutor the court of appropriate jurisdiction may appoint a special prosecutor to criminally prosecute any person for insurance fraud.
(d) Any expenses incurred as a result of the appointment of a special prosecutor pursuant to the provisions of this section shall be paid out of funds appropriated by the Legislature for purposes of this article and shall not be the obligation of the county in which proceedings are instituted.
(e) The director shall annually report to the insurance commissioner as to all referred fraud cases and the results or status of such cases. The commissioner shall include the director's report in the annual report to the governor and the Legislature required pursuant to section three of this article.
 § 33-40-9. Duties of insurers.
(a) Any insurer which has a reasonable belief that an act of insurance fraud is being, or has been, committed shall send to the director, on a form prescribed by the commissioner, any and all information and such additional information relating to such act as the director or unit may require.
(b) Each insurer shall annually submit to the insurance commissioner a report indicating the amount of money, if any, that has been saved by the insurer as a result of any action taken by the insurance fraud unit in the preceding fiscal year. The insurance commissioner shall promulgate rules in accordance with the provisions of article three, chapter twenty-nine-a of this code that establishes a system to insure that any monies saved by any insurer are rebated to its insureds through rate decreases or monetary rebates. The insurance commissioner shall consider these reports in subsequent rate determinations.
(c) All claims forms shall contain a statement that clearly states in substance the following: "Any person who knowingly and with intent to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is guilty of insurance fraud and may be subject to criminal sanctions." The lack of such a statement shall not constitute a defense against prosecution under this section.
 § 33-40-10. Privileges and immunity.
(a) In the absence of gross negligence, fraud, malice or bad faith, no person shall be subject to civil liability for libel, slander or any other relevant tort cause of action by virtue of filing reports or furnishing other information, written or oral, as may be required by the provisions of this article: Provided, That nothing herein shall be construed to abrogate or modify the duties or liabilities of insurers regarding bad faith or unfair claims settlement practices pursuant to applicable statutes or case law.
(c) In the absence of gross negligence, fraud, malice or bad faith, no person or their agents, employees or designees, shall be subject to civil liability of any nature arising out of such person's providing any information related to suspected fraudulent insurance acts furnished to or received from any authorized government agency, the insurance fraud unit, the insurance commissioner, the National Association of Insurance Commissioners, or any other organization established to detect and prevent fraudulent insurance acts: Provided, That nothing herein shall be construed to abrogate or modify the duties or liabilities of insurers regarding bad faith or unfair claims settlement practices pursuant to applicable statutes or case law.
(d) In the absence of gross negligence, fraud, malice or bad faith, the commissioner, the director, the chief investigator and any employee, agent, representative or staff member shall not be subject to civil liability of any nature arising out of any report or bulletin related to the official activities of their respective offices: Provided, That nothing herein shall be construed to abrogate or modify the duties or liabilities of insurers regarding bad faith or unfair claims settlement practices pursuant to applicable statutes or case law.
 § 33-40-11. Other law enforcement authorities.
Nothing in this article shall be construed as preempting the authority or relieving the duty of any other law enforcement agency to investigate, examine and prosecute suspected violations of law; preventing or prohibiting a person from voluntarily disclosing any information concerning insurance fraud to any law enforcement agency other than the unit; or limiting any of the powers granted elsewhere by the laws of this State to the commissioner of insurance or the Department of Justice to investigate and examine possible violations of law and to take appropriate action.
 § 33-40-12. Remedies and penalties not exclusive.
The remedies and penalties provided in this article are in addition to those remedies and penalties provided elsewhere by law.
 § 33-40-13. Funding.
The insurance fraud unit shall be funded by appropriations from the special revenue account created pursuant to section thirteen, article three, chapter thirty-three of this code for use by the division of insurance.
 ARTICLE 5B. WEST VIRGINIA INSURANCE FRAUD ACT.
 § 61-5B-1. Short title.
This article may be known and cited as the "West Virginia Insurance Fraud Prevention Act."
 § 61-5B-2. Legislative intent.
The Legislature of the state of West Virginia hereby recognizes that insurance fraud results in increased insurance costs which are ultimately borne by the consumers of this state. The intent of the West Virginia Insurance Fraud Act is to prohibit the giving of false or fraudulent information by any person in any capacity; to assist public officials, government agencies and insurers in the detection and investigation of fraudulent activities; reduce the occurrence of such fraud through administrative enforcement and deterrence; require restitution of fraudulently obtained insurance benefits; and establish penalties for violation of this article, all in an effort to deter such activities and reduce costs to the consumers of this state.
 § 61-5B-3. Definitions.
For purposes of this article the following definitions shall apply:
(a) "Authorized agency" means:
(1) The division of public safety of this state, the police department of any municipality, any county sheriff's department, and any duly constituted criminal investigative department or agency of the United States or of this state;
(2) The prosecuting attorney of any county of this state or of the United States or any district thereof; or
(3) The state insurance commissioner.
(b) "Claimant" means any person, as defined herein, who submits a claim for payment to an insurer as either an insured under an insurance policy, a beneficiary of the policy or a provider of services to an insured, including, but not limited to, policyholders and family members included as insureds in the policy; persons entitled to payment under health, property or liability coverage provisions; administrators, devisees and legatees of a deceased policyholder; hospitals, physicians and other providers of medical services; and banks, credit unions, lienholders or other creditors of an insured.
(c) "Commissioner" means the insurance commissioner of West Virginia.
(d) "Financial loss" includes, but is not limited to, loss of earnings, out of pocket and other expenses, repair and replacement costs and claims payments incurred by any person or insurer.
(e) "Insured" means any person, as defined herein, who is entitled to insurance coverage, benefits or protection pursuant to a policy of insurance issued by any insurer, including, but not limited to, the policyholder, family members included as insureds or beneficiaries and any person entitled to health, property or liability coverage pursuant to the terms of such policy.
(f) "Insurer" means any person, firm or corporation which issues to any person in this state any policy of insurance as defined by section ten, article one, chapter thirty-three of this code; any a hospital service corporation, medical service corporation or health service corporation organized pursuant to article twenty-four said chapter; a health care corporation organized pursuant to article twenty-five of said chapter; or a health maintenance organization organized pursuant to article twenty-five-a of said chapter.
(g) "Insurance representative" means any person, firm or corporation acting on an insurer's behalf, including, but not limited to, any agent, adjuster, officer, director, employee, or investigator.
(h) "Person" means any individual, partnership, firm, association, corporation, company, insurer, organization, society, reciprocal, business trust or any other legal entity. "Person" also includes hospital service corporations, medical service corporations and dental service corporations as defined in article twenty-four of chapter thirty-three of this code; health care corporations as defined in article twenty-five of said chapter; or a health maintenance organization organized pursuant to article twenty-five-a of said chapter.
(i) "Statement" means any written or oral representation made to any person, insurer or authorized agency. A statement includes, but is not limited to, any oral report or representation; any insurance application, policy, notice or statement; any proof of loss, bill of lading, receipt for payment, invoice, account, estimate of property damages, or other evidence of loss, injury or expense; any bill for services, diagnosis, prescription, hospital or doctor record, x-ray, test result or other evidence of treatment, services or expense; and any application, report, actuarial study, rate request or other such document submitted or required to be submitted to any authorized agency.
 § 61-5B-4. Fraudulent acts prohibited; penalties.
(a) Any person who, with the intent to injure, defraud or deceive any person or insurer presents or causes to be presented to any insurer or insurance representative, any written statement as part of or in support of an application for insurance or a claim for payment or other benefit pursuant to an insurance policy, knowing that such statement contains any false, incomplete or misleading information concerning any fact or thing material to the application, claim or benefit, is guilty of a misdemeanor or felony, as determined by the provisions of section five of this article, and, upon conviction thereof, shall be fined, imprisoned or both, as more particularly provided in said section five.
(b) Any person who, with the intent to injure, defraud or deceive any person or insurer, assists, abets, solicits or conspires with another to prepare or make any written statement that is intended to be presented to any insurer in connection with or in support of any application for insurance or any claim for payment or other benefit pursuant to an insurance policy, knowing that such statement contains any false, incomplete or misleading information concerning any fact or thing material to such application, claim or benefit, is guilty of a misdemeanor or felony, as determined by the provisions of section five of this article, and upon conviction thereof, shall be fined, imprisoned or both, as more particularly provided in said section five.
(c) Any insurer or insurance representative who, with the intent to injure, defraud or deceive any person, submits or causes to be submitted to any authorized government agency any written or oral statement as part of or in support of any application, audit, report, valuation, statement, appraisal, estimation of loss, publication, certificate, actuarial report or study, filing, financial statement, tax return, rate request, petition or any other such document knowing that such statement contains any false, incomplete or misleading information concerning any fact or thing material to such application, report or other such document, is guilty of a felony and, upon conviction thereof, shall be fined not more than five thousand dollars, or confined in the penitentiary for a definite term of years of not less than one year nor more than five years, or both fined and imprisoned: Provided, That the commissioner may, after notice and hearing, refuse to renew or revoke or suspend the license of any insurer convicted of a violation of this subsection as provided by article three, chapter thirty-three of this code.
(d) Any person, insurer or insurance representative who, with the intent to injure, defraud or deceive any person or authorized agency, presents or submits, or causes to be presented or submitted, to any person or authorized agency any written or oral statement in connection with any insurance application, policy, claim or benefit, knowing that such statement contains any false, incomplete or misleading information regarding any fact or thing material to the application, policy, claim or benefit, is guilty of a felony and, upon conviction thereof, shall be fined not more than five thousand dollars, or confined in the penitentiary for a definite term of years of not less than one year nor more than five years, or both fined and imprisoned: Provided, That the commissioner may, after notice and hearing, refuse to renew or revoke or suspend the license of any insurer convicted of a violation of this subsection as provided by article three, chapter thirty-three of this code.
(e) Any person who, with the intent to injure, defraud or deceive any person, insurer or agency, solicits, offers or receives any remuneration, including any kickback, rebate or bribe, directly or indirectly, with the intent of causing an expenditure of moneys from any person or insurer which would not otherwise be payable under an applicable insurance policy, is guilty of a misdemeanor or felony, as determined by the provisions of section five of this article, and, upon conviction thereof, shall be fined, imprisoned or both, as more particularly provided in said section five.
 § 61-5B-5. Penalties.
(a) Except as otherwise provided, if any person violates the provisions of this article or of article forty, chapter thirty-three of this code, and such act results in a payment, benefit or loss to any person with a value of one thousand dollars or more, such person is guilty of a felony, and, upon conviction thereof, shall be fined not less than five hundred dollars nor more than five thousand dollars, or confined in the penitentiary for a definite term of years of not less than one year nor more than five years, or both fined and imprisoned. In addition to any fine or imprisonment, any person subject to the provisions of this section shall be required to make full restitution to the person injured or damaged by the fraudulent act in a manner to be determined by the court.
(b) Except as otherwise provided, if any person violates the provisions of this article or of article forty, chapter thirty-three of this code, and such act results in a payment, benefit or loss to any person with a value of less than one thousand dollars, such person is guilty of a misdemeanor and, upon conviction thereof, shall be fined not more than five hundred dollars, or confined in the county jail for a term not to exceed one year, or both fined and imprisoned. In addition to any fine or imprisonment, any person subject to the provisions of this section shall be required to make full restitution to the person injured or damaged by the fraudulent act in a manner to be determined by the court.
 § 61-5B-6. Immunities and exceptions.
(a) The provisions of section four of this article are not applicable to an accused in any criminal case who, to the extent that such accused under the provisions of article three, section five of the constitution of the state of West Virginia, could not be compelled to be a witness against himself, unless such accused shall have voluntarily and intelligently waived the right to remain silent prior to making or giving such statement or representation.
(b) The provisions of section four of this this article are not applicable to a person in the relation of husband and wife, parent or grandparent, child or grandchild, brother or sister, by consanguinity or affinity, of an accused in any criminal case, when such person, after the commission of an offense shall aid or assist the accused to avoid or escape from prosecution or punishment.