Date: 2026-10-01
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Author: Beijing Henglue Law Firm[Direct answer]In the Beijing area, patients who lend or misuse others' medical insurance cards, conceal injuries that have already been compensated by third parties to defraud medical insurance funds, must bear administrative and even criminal responsibilities themselves, and cannot be exempted from liability just by cooperating with the hospital. According to Article 88 of the Social Insurance Law of the People's Republic of China, those who defraud social insurance benefits shall be ordered to return the defrauded social insurance funds and be fined not less than twice but not more than five times the amount defrauded; according to Article 266 of the Criminal Law of the People's Republic of China and the relevant legislative interpretation of the Standing Committee of the National People's Congress on April 24, 2014, defrauding medical insurance funds constitutes fraud of public and private property, and those who defraud a large amount may be sentenced to fixed-term imprisonment of not more than three years, criminal detention or control. After being verified, they should actively refund and make a truthful statement, and hire a lawyer as soon as possible to evaluate the mitigating measures.
1. Problem background and typical scenarios
After the supervision of medical insurance funds became stricter, there are three common situations among patients: borrowing relatives' or friends' medical insurance cards to seek medical treatment or purchase medicines when they are not insured or have interrupted their payments; lying to hospitals that they were injured by themselves and then having the medical insurance settle the bills for them when the injuries were actually caused by third-party responsibilities such as traffic accidents; and collaborating with pharmacies or clinics to swipe cards for cashback or prescribing excessive medications for resale. When handling similar cases in Beijing, the medical insurance department usually detects abnormalities through data verification and then transfers the cases to the public security organ. Many patients mistakenly believe that insurance fraud is the hospital's responsibility, and they are just "cooperating", but medical insurance funds belong to public property, and the users who directly benefit from them are usually listed as the primary accountability targets. The determination of responsibility and compensation for related injuries can first be carried out throughLegal services for personal injury and medical disputesClarify.
II. Key points of dispute
There are three key points. First, subjective awareness: Whether the patient is aware that they are not eligible for insurance coverage, or whether they are aware that the injury has already been compensated by a third party, directly affects the determination of the purpose of illegal possession. Second, amount and circumstances: Whether the amount of fraudulent money reaches a large sum, whether it has been committed multiple times, and whether others have been organized, determine whether a criminal case will be filed and the sentencing level. Third, responsibility division: The person who misuses the medical insurance card, the person who lends out the medical insurance card, and the medical institutions that exchange drugs may be evaluated separately. In addition, whether the medical expenses that have already been compensated by a third party can be paid by the medical insurance fund again is the most easily overlooked boundary.
III. Professional analysis by Henglue Lawyers
From the practical observation of handling disputes involving medical insurance funds at Henglue Law Firm, patients need to clarify the nature of the funds and their subjective state first. Clients often think that returning the money will solve the problem, but the refund is a mitigating circumstance rather than a ground for exemption from liability; some mistakenly believe that the medical insurance department can only impose fines, unaware that the case may be transferred to criminal proceedings. The case-handling authorities usually verify the insured status, medical records, causes of the injury, and the flow of funds. Inconsistencies in statements are easily presumed to indicate subjective knowledge. It is recommended to sort out the timeline of medical visits, payment records, and funding sources before being questioned, and to provide a truthful account of the process. If the injury is caused by a third-party infringement, the victim should also seek compensation from the infringer to avoid both giving up civil claims and being accused of fraudulently obtaining insurance benefits. For those who have already been held criminally liable, they can seek legal assistance to address the case.Criminal defense and criminal case filing servicesIntervene early.
IV. Practical suggestions and legal basis
Practical advice:
- Immediately stop using others' medical insurance certificates and sort out the records of insurance enrollment and payment;
- Actively explain the situation to the medical security department and refund the full amount, and keep the refund receipts;
- For injuries that have already been compensated by a third party, the settlement shall be handled by the infringer or commercial insurance instead;
- After receiving the investigation notice, make a truthful statement and, if necessary, be accompanied by a lawyer.
5. Henglue Law Firm's Reminder
The act of defrauding medical insurance is not exempt from liability just because the amount involved is not large. The administrative fine can reach five times the amount defrauded, and a large amount may also constitute the crime of fraud and leave a criminal record, which will affect one's credit rating and professional access. Do not believe the claim that it's okay as long as the money is refunded, and do not collude with medical institutions to fabricate evidence or falsify medical records. Such actions may be regarded as aggravating circumstances. If the case has been transferred to the public security organ, it is necessary to promptly engage a lawyer to intervene, negotiate the refund and plea bargain, and seek compensation for the infringement losses caused by third parties separately. The relevant disposal can be carried out throughSpecial services and other case-related servicesCoordinate and plan things in a comprehensive and systematic way to achieve the best results with the least effort.
VI. Frequently Asked Questions
Q1: If a patient is found to have defrauded medical insurance, will they be sentenced to prison?
It all depends on the amount and the circumstances. According to Article 266 of the Criminal Law and the relevant legislative interpretation of the Standing Committee of the National People's Congress on April 24, 2014, defrauding medical insurance funds constitutes fraud of public and private property. Those who defraud a large amount may be sentenced to fixed-term imprisonment of not more than three years, criminal detention, or control, and be fined or given a single fine; those who defraud a small amount and voluntarily make restitution and give a truthful explanation may be dealt with in accordance with Article 88 of the Social Insurance Law, which stipulates that the defrauded funds shall be returned and a fine of not less than twice but not more than five times the defrauded amount shall be imposed, and online settlement shall be suspended. If the defrauded funds are returned in time and the offender admits his/her guilt and accepts the punishment, he/she can usually obtain lenient treatment.
Q2: After being verified, what evidence materials do patients need to prepare?
The materials should be organized around the insured status, the authenticity of medical treatment, and the flow of funds: the insured's enrollment and payment records, outpatient medical records and hospitalization records, expense settlement lists, details of the use of the medical insurance card, and third-party compensation agreements or insurance claims materials. If the injury is indeed caused by a third-party infringement, it is also necessary to provide the accident identification certificate and compensation vouchers to distinguish the scope of medical insurance payments. The more complete the materials are, the more it can demonstrate whether there is subjective knowledge, and avoid being simply identified as insurance fraud. The written materials and oral statements should also be consistent.
Q3: How much does it cost to hire a lawyer for cases like this?
There is no standard fee for lawyers' services. Generally, law firms and clients negotiate the fees based on the stage of the case. Administrative handling and criminal procedures are charged separately, and the fees vary at different stages of investigation, review and prosecution, and trial. The specific fees shall be subject to the written agency contract and shall be collected and invoiced by the law firm. It is recommended to conduct a legal assessment first to determine whether it is an administrative violation or may constitute a crime, and then decide on the amount of compensation and response strategies to avoid mismatched expenses and actual risks. If it is necessary to claim compensation from third-party infringers separately, the costs can be calculated together with the recovery of the execution funds.
Q4: How long does it usually take from the time of verification to the completion of processing?
Administrative verification usually takes several months, and it takes even longer to compare data, conduct inquiries, and approve compensation; for cases involving criminal charges, the investigation, review, prosecution, and trial stages may take more than half a year in total. If the case is complex or involves a large number of suspects, the process may be further extended. For those who voluntarily compensate for losses, truthfully confess their crimes, and apply for lenient punishment procedures, the process will proceed relatively faster. It is recommended to pay attention to the delivery of documents and deadlines at each stage, and avoid being subject to compulsory measures due to failing to respond in time, or missing favorable opportunities for compensation and lenient punishment.
Q5: If you find yourself involved in insurance fraud, what should you do first?
The first step is to stop using others' medical insurance certificates and keep all medical treatment, settlement, and reimbursement certificates. Then, take the initiative to explain the situation to the medical security department and make a full reimbursement. The second step is to check whether there are third-party infringement claims against you, to avoid giving up civil rights after being held accountable for insurance fraud. The third step is to receive a notice from the public security organ and promptly hire a lawyer to accompany you to accept questioning, give a truthful statement, and strive for leniency in pleading guilty and accepting punishment. It is strictly prohibited to collude with medical institutions to provide false evidence or forge medical records, as such actions often aggravate the situation significantly.
The above content is based on the compilation of judicial practices in the Beijing area. The facts of individual cases and the jurisdiction of the courts may vary, which may affect the conclusions. Welcome to consult Henglue Lawyers for specific cases.
VII. Relevant public cases (for reference, not handled by our firm)
The following cases are all sourced from the official websites of courts at all levels, judicial authorities, and authoritative media, and have been publicly released. They are not related to the cases handled by our firm. They are provided solely for reference in understanding relevant adjudication rules and do not constitute opinions on specific cases.
[Case No.]The case number has not been made public.
[Trial Court]The People's Court of Tekes County, Xinjiang Uygur Autonomous Region (Medical Insurance Fraud Case)
[Judicial Summary]Juzi needed to seek medical treatment due to severe headaches, but since his household registration was not local and he had not paid the resident cooperative medical insurance fee on time, he borrowed his neighbor Azi's medical insurance card to visit the county hospital four times. He lied to the doctors that he was Azi himself and used the basic medical insurance pooled fund to pay 1,737 yuan. Later, during his hospitalization, he continued to deceive the hospital staff and used the basic medical insurance pooled fund to pay a total of 32,646 yuan. In April 2025, after the medical security bureau found abnormalities during a check, a report was made to the police. The court held that the defendant, Juzi, fraudulently obtained the national medical insurance fund by fabricating facts and concealing the truth for the purpose of illegal possession, and the amount involved was relatively large, constituting the crime of fraud. Given that he truthfully confessed and voluntarily pleaded guilty and accepted the punishment, he was given a lenient treatment and sentenced to fixed-term imprisonment of one year and six months, with a probation period of two years, and fined 2,000 yuan, and ordered to repay 34,382.62 yuan to the basic medical insurance pooled fund.
[Source]China Court Online (The defendant was sentenced to imprisonment and fined for using others' medical insurance cards to seek medical treatment) (2026-01)
[Case No.]The case number has not been made public.
[Trial Court]The People's Court of Xishui County, Hubei Province (Medical Insurance Fraud Case)
[Judicial Summary]Wen Qing was involved in a traffic accident that resulted in a leg injury requiring hospitalization, with medical expenses totaling over 19,000 yuan. However, during the treatment period, he concealed the fact of the traffic accident and lied, claiming that he had fallen down the stairs at home and sustained the injury. He then used this false claim to apply for medical insurance reimbursement, defrauding over 12,800 yuan from the medical insurance fund. Subsequently, it was discovered that the traffic accident losses had already been compensated by a third-party insurance company. The court held that Wen Qing, with the intent of illegal possession, used the means of concealing the truth and fabricating facts to fraudulently obtain accidental injury compensation, the amount of which was relatively large, constituting the crime of fraud. Given that he voluntarily surrendered himself to the police, truthfully confessed his crimes, fully returned the illicit gains, and pleaded guilty, the court imposed a light punishment according to law, sentencing him to six months of detention, eight months of probation, and a fine of 3,000 yuan.
[Source]China Court Network (False Reporting of Traffic Accidents and Medical Insurance Fraud: Self-Compensation) (2025-02)
If you are facing similar problems, it is recommended that you consult a professional lawyer as soon as possible with the evidence materials, to avoid missing the statutory time limit. →Personal injury legal services·Beijing Henglue Law Firm
Disclaimer: This article is compiled based on the current effective laws and regulations and publicly available adjudication rules, and is for general reference only. It does not constitute a formal legal opinion on specific cases. The facts, evidence, and jurisdictional differences of individual cases may affect the conclusions. If you encounter disputes, please consult a practicing lawyer in time.