Page 243 - Ebook health insurance IC27

Sashi Publications

Important Points to Remember

Health Insurance is the fastest growing industry in India.
However it is badly affected by the menace of false claims.
False medical insurance claims have now an organized
racket with hospitals, patients (insurance policy holders)
and even the policy handlers from the insurer and
intermediaries. In India, statistics are also alarming.

According to the survey conducted two years back by
one of the leading TPA the number of false claims in the
industry is estimated at around 10-15 per cent of total claims.

The report suggests that the Health care industry in India is losing approximately Rs 600
crore on "false claims" every year. So to make health insurance viable there is a need to
focus on eliminating or reducing fraudulent claims.

Health insurance fraud is described as an intentional act of deceiving, concealing, or
misrepresenting information that results in health care benefits being paid illegitimately to
an individual or group.

'Abuse' is defined as Provider practices that are inconsistent with sound fiscal, business,
or medical practices, and result in an unnecessary cost to Health programs, or in
reimbursement for services that are not medically necessary or fail to meet professionally
recognized standards for health care.

It also includes recipient practices that result in unnecessary costs to the Health program.
The main purpose of fraud or abuse is financial gain. Fraud and abuse are widespread
and very costly to the health-care system.

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