Page 34 - The Insurance Times July 2020

Be careful about the health insurance fraud: and the maximum 65. Dependent children shall be
The most common perpetrators of healthcare insurance covered from the age of three months to 25 years. It
fraud are health care providers. One reason for this is that also offers the family floater option. Most insurers could
the historically prevailing attitude in the medical profession offer a discount on this. The tenures could be 3.5, 6.5
is one of "fidelity to patients". This incentive can lead to or 9.5 months, including the 15-day waiting period, and
fraudulent practices such as billing insurers for treatments insurance rules such as lifelong renewability, migration
that are not covered by the patient's insurance policy. To and portability shall not be applicable. The minimum
do this, physicians often bill for a different service, which is sum insured is Rs. 50,000, which can be increased in
covered by the policy, than that which was rendered. multiples of Rs. 50,000, up to Rs. 5 lakh.
Another motivation for insurance fraud in the healthcare 3. Any co-morbid condition triggered due to covid-19 shall
industry, just as in all other types of insurance fraud, is a be covered. However, a few insurers may apply loading
desire for financial gain. on premiums for individuals with co-morbidities. For
instance, New India Assurance shall apply a 30%
Public healthcare programs such as Medicare and Medicaid loading on premiums for individuals with diabetes,
are especially conducive to fraudulent activities, as they are hypertension, asthma, lung fibrosis, cancer and so on.
often run on a free-for-structure. Physicians use several
fraudulent techniques to achieve this end. These can include 4. The policy has no sub-limits on room rent, which is an
"up-coding" or "upgrading," which involve billing for more advantage. Capping of room rent usually results in
expensive treatments than those actually provided; increased out-of-pocket expenditure. It also has a
providing and subsequently billing for treatments that are bearing on other associated costs such as nursing and
doctors' fees. The policy has no sub-limits on room rent,
not medically necessary; scheduling extra visits for patients;
referring patients to another physician when no further which is an advantage. Capping of room rent usually
treatment is actually necessary; and "ganging," or billing for results in increased out-of-pocket expenditure. It also
services to family members or other individuals who are has a bearing on other associated costs such as nursing
accompanying the patient but who did not personally and doctors' fees.
receive any services. 5. The policy comes with an optional hospital daily cash
cover in which the insurer will pay up to 0.5% of the
One of the main reasons that medical fraud is such a sum insured for every 24 hours of hospitalization up to
prevalent practice is that nearly all of the parties involved 15 days. The base policy will pay for hospitalization
find it favorable in some way. Many physicians see it as expenses incurred for the treatment of covid-19 on a
necessary to provide quality care for their patients. Many positive diagnosis from a government-approved
patients, although disapproving of the ideal of fraud, are diagnostic centre.
sometimes more willing to accept it when it affects their
own medical care. Program administrators are often lenient 6. The policy covers costs of at-home treatment, provided
on the issue of insurance fraud, as they want to maximize the medical practitioner advises home treatment and
the services of their providers. there is a continuous active line of treatment, which
requires monitoring by a medical practitioner.
Introduction of corona kavach insurance policy 7. The premiums shared by insurers across age groups (as
- special drive by general insurance industry: reported by media) that are found that Future Generali
1. As mandated by the Insurance Regulatory and India Insurance Co. Ltd and some cases of public sector
Development Authority of India (IRDAI), standalone insurers such as Oriental Insurance Co. Ltd and United
health and general insurance companies started India Insurance Co. have priced it at the lower end of
offering the standard indemnity health insurance policy- the spectrum, whereas Go Digit General Insurance Ltd
Corona Kavach. While some insurers currently don't pay is at the higher end.
for the cost of personal protective equipment (PPEs) and 8. For an individual between ages 31 and 35 years, for a
other hygiene-related consumables, which form a chunk sum insured of Rs. 3 lakh and tenure of 9.5 months,
of the hospital bills, the Corona Kavach will pay for PPEs, Future Generali has priced the base product at Rs. 664,
gloves, masks and other similar expenses. Though the plus taxes, whereas Go Digit has priced it at Rs. 8,085,
features and wordings of the policy are the same across plus taxes. Oriental and United India have priced it at
insurers, BUT there's a difference in the way insurers Rs. 932 and Rs. 1,192, respectively, plus taxes.
have priced it. 9. IRDAI has mandated a 5% discount for all healthcare
2. The minimum entry age for the policy shall be 18 years workers. A few companies are also offering discounts

34 The Insurance Times, July 2020