PIP Denied for “Suspected Fraud”? What Florida Law Requires Before an Insurer Can Make That Accusation Stick
You were hurt in a crash and filed a PIP claim. Then a letter arrived saying your claim is “under investigation for suspected fraud,” or has been referred to the insurer’s Special Investigations Unit. Maybe it has already been denied. The word “fraud” in a letter from your own insurance company is frightening, especially when you’ve done nothing wrong.
Can a Florida insurer deny PIP for suspected fraud? It can investigate, but on a strict clock. Under section 627.736(4)(i), Florida Statutes, an insurer that suspects fraud must notify you in writing within 30 days of the claim. It then has 60 more days to investigate, and no later than 90 days after the claim it must pay, with interest, or deny. A suspicion isn’t proof. Under section 627.736(4)(h), fraud voids PIP coverage only if it’s admitted in a sworn statement or established in court.
I’m Alexander Licznerski. I challenge unsupported fraud denials for injured people across Tampa Bay. I’ll also tell you plainly if your situation calls for a different kind of lawyer.
Call 813-934-3519 or fill out the online contact form. You’ll reach me directly.
What a “Suspected Fraud” Letter Is, and What It Isn’t
Every auto insurer has a Special Investigations Unit (SIU), its internal fraud department. Claims get sent there for many reasons. Some involve real red flags. Many are flagged automatically by software, or because of who else is connected to the claim: a particular clinic, body shop, or law firm on the insurer’s watch list, or a prior claim in an industry database.
A suspected-fraud letter is:
- A notice that the insurer is taking more time to investigate
- Often a prelude to an examination under oath, records requests, or recorded statements
- Sometimes a denial labeled “fraud” without much behind it
A suspected-fraud letter is not:
- A criminal charge
- A finding that you did anything wrong
- Permission for the insurer to hold your claim indefinitely
One thing worth knowing: Florida law requires insurers to report claims denied for suspected fraud to the state’s insurance fraud investigators. Most of those reports go nowhere, but it’s a reason to handle the denial carefully rather than ignore it. See “When It’s More Than a Payment Dispute” below.
The Rules Insurers Must Follow
| Rule | What Florida law says | Where |
|---|---|---|
| Fraud notice within 30 days | If the insurer reasonably believes a fraudulent insurance act occurred, it must notify the claimant in writing within 30 days after the claim is submitted | § 627.736(4)(i) |
| 60 more days to investigate | After that first 30 days, the insurer gets an additional 60 days | § 627.736(4)(i) |
| Pay or deny by day 90 | No later than 90 days after the claim is submitted, the insurer must deny it, or pay it with interest running from the day it was submitted | § 627.736(4)(i) |
| Itemized explanation | A denial must specify each item not paid and give a name, address, and claim number for your response | § 627.736(4)(b)2 |
| What it takes to void coverage | Fraud voids PIP coverage only if it is admitted in a sworn statement by the insured or established in court | § 627.736(4)(h) |
| Fees if the insurer sues and loses | In an insurer’s action to recover benefits it claims were paid because of fraud, the prevailing party gets attorney’s fees and costs, and that includes you | § 627.736(4)(h) |
Why the timeline matters. An insurer that never sent a written fraud notice within 30 days, or let the claim sit past 90 days without paying or denying, may have breached the statute. Some Florida courts have considered whether that kind of delay prevents the insurer from relying on later fraud or misrepresentation defenses. The answer depends on the facts and the court, but the dates are always the first thing to check.
Why the voiding standard matters. Insurers sometimes write “fraud” in a denial letter as though the word settles the matter. It doesn’t. To void your PIP coverage for fraud, the law requires either your own sworn admission or a court finding. Until then, a fraud denial is the insurer’s position, and it can be challenged like any other.
The honest limit. That high bar applies to voiding all of your PIP coverage. Insurers can still dispute particular bills on narrower grounds. For example, the statute says no one has to pay charges submitted by someone who knowingly made a false or misleading statement about them, or for services that weren’t lawfully rendered. Those defenses still have to be proven, but they don’t require your admission or a prior court finding.
Common “Fraud” Labels, and What’s Often Behind Them
| What the letter says | What’s often really going on |
|---|---|
| “Suspected staged accident” | A low-speed crash, several people in the car, or occupants who know each other. None of that is fraud. The insurer has to prove the crash was intentional. |
| “Questionable claim” or “SIU referral” | Software flagged the claim, or a clinic, body shop, or law firm connected to it is on a watch list. The flag says nothing about you. |
| “Inconsistent statements” | Small differences between a police report, a recorded statement, an EUO, and medical intake forms, often about speed, timing, or seating. Ordinary memory differences aren’t fraud. |
| “Prior injury not disclosed” | An old injury the insurer found in an industry database. Whether it matters depends on what you were asked and whether it relates to the current injuries. |
| “Services not rendered” or “billing irregularities” | A dispute about the clinic’s billing, not your conduct. You may still be entitled to benefits for care you actually received. |
| “Solicitation” or “patient brokering” | An allegation that someone steered you to a clinic or lawyer. If that happened without your knowledge, it’s a problem with them, not you, though it can affect which bills are payable. |
| “Material misrepresentation” | Often a rescission, not a fraud finding. It has its own rules. |
Where Fraud Denials Go Wrong: A Checklist
- No written fraud notice within 30 days of the claim.
- No decision by day 90. The claim sat without payment or denial past the statutory deadline.
- No interest paid on a claim eventually paid after a fraud investigation.
- “Fraud” with no facts. The denial doesn’t say what was supposedly false, who said it, or when.
- Voiding without the required proof. The insurer treats all PIP coverage as void without a sworn admission or a court finding.
- Guilt by association. The only “evidence” is the identity of a clinic, body shop, or lawyer connected to the claim.
- Ordinary inconsistencies. Minor differences in recollection are treated as intentional lies.
- Everyone denied for one person’s issue. Claims of passengers or household members are denied over an allegation that concerns someone else.
- No itemized explanation. The denial lacks the item-by-item specification, response address, and claim number the statute requires.
None of these automatically wins a case. Each is a reason the denial may not hold up.
What to Do Now
If you’re the patient
- Write down the dates. When you submitted the claim, when you received the fraud notice, and when anything was paid or denied. Keep every letter and envelope.
- Don’t give a recorded statement or sign new authorizations before the letter has been reviewed.
- Take any EUO notice seriously. Fraud investigations often lead to one, and missing it can cost you the claim. [Link: EUO Denials]
- Don’t guess or embellish. If you’re asked questions, accurate and complete answers protect you. “I don’t remember” is a fine answer when it’s true.
- Get the letter reviewed early. The 30- and 90-day deadlines are where these cases are often won.
Call 813-934-3519 or fill out the online contact form. I’ll review it myself, usually the same business day.
If you’re a medical provider or billing team
A fraud flag on one claim can freeze payment on every patient connected to your clinic. I represent patients, not practices, but restoring a wrongly denied patient claim resolves the bills tied to it. Your practice pays no legal fees. If the insurer is alleging fraud against your practice itself, you need your own counsel.
Email a de-identified list of fraud-flagged denials to [email protected], or call 813-934-3519. Denials from the last five years may still be recoverable.
If you’re a personal injury attorney
A PIP fraud flag often comes before a bodily injury defense built on the same theory: staged accident, prior injury, or inconsistent statements. Fighting it on the PIP side tests the insurer’s theory early, under strict statutory deadlines. I handle the PIP side only. I put a written non-solicitation commitment on every referral, and your client stays your client.
Call 813-934-3519 or email the denial to [email protected]. You’ll get a straight answer, usually within two business days.
When It’s More Than a Payment Dispute
Most fraud letters are claim-handling tactics. Occasionally, though, a situation crosses into possible criminal exposure. Here is when to treat it that way:
- A state investigator contacts you. That could be someone from the Florida Department of Financial Services’ insurance fraud investigators (the Division of Investigative and Forensic Services) or a police detective.
- You receive a subpoena or are asked to come in for an interview.
- The allegation is specific and serious, such as an intentionally staged crash, or services billed that never happened.
If any of that happens, don’t give a statement to an investigator without a criminal defense lawyer. My practice handles PIP and insurance disputes, not criminal defense. If your situation needs a criminal lawyer, I’ll tell you so plainly and point you to one.
One more thing, said plainly: I don’t take claims I believe are fraudulent. The cases I take are ones where the insurer used the word “fraud” without the facts or the procedure to back it up.
PIP Fraud Denial FAQ
My PIP claim is “under investigation for suspected fraud.” Am I in trouble?
Usually not. Insurers flag many claims for review, often automatically. A fraud investigation by your insurer is not a criminal charge. If a state investigator or police contact you, though, talk to a criminal defense lawyer before giving any statement.
How long can my insurer investigate my PIP claim for fraud?
It must notify you in writing within 30 days of the claim, then has 60 more days. No later than 90 days after the claim, it must pay with interest or deny.
What does it mean that my claim was sent to SIU?
The Special Investigations Unit is the insurer’s internal fraud department. A referral means more scrutiny, often including records requests or an examination under oath. It isn’t a finding of wrongdoing.
Can my insurer void my PIP coverage just by saying “fraud”?
No. Under section 627.736(4)(h), fraud voids PIP coverage only if it’s admitted in a sworn statement or established in court. Insurers can still dispute specific bills on other grounds, which they must prove.
The insurer says my accident was staged. What now?
The insurer has to prove the crash was intentional. Low speed, multiple occupants, or occupants who know each other don’t prove that. Keep your photos, repair records, police report, and witness information.
The insurer says my clinic is under investigation. Does that affect me?
It can delay payment, but an investigation of a clinic isn’t a finding against you. You may still be entitled to benefits for care you actually received.
Can I recover attorney’s fees if the insurer is wrong?
It depends on the case. If the insurer sues you to recover PIP benefits it claims were paid because of fraud and loses, the statute awards fees to the prevailing party. Other fee routes depend on how the claim is brought. I’ll explain before you sign anything.
Does it cost anything to have my fraud denial reviewed?
No. Call or email it to me and I’ll review it at no charge.
Get Your Fraud Denial Reviewed
“Fraud” is the most serious word an insurer can put in a letter, and Florida law makes it earn that word. The deadlines are strict, the proof required to void coverage is high, and the dates in your letters often matter more than anything else.
Call 813-934-3519 or fill out the online contact form. Patients, medical practices, and injury attorneys all reach me the same way: directly.
Serving Hillsborough, Pinellas, Pasco, Hernando, Citrus, Sumter, Polk, Manatee, and Sarasota counties from Oldsmar.
Boutique Representation. Real Results. Your Attorney, Not a Case Number.
This page provides general information about Florida law and is not legal advice. Licznerski Law, PLLC does not handle criminal defense matters. Every case depends on its facts. Contacting the firm does not create an attorney-client relationship.