Page 258 - Ebook health insurance IC27

The Insurance Times

member or the provider and at times are a concerted effort of agents, brokers,
insurance employees, insured members, the service providers, and other
stakeholders of the healthcare system.

Q3. Distinguish between health insurance and general insurance frauds.
Ans. Health Insurance and Motor Insurance in General Insurance are most prone to

frauds. Documents such as fake medical bills and certificates are commonly used
to defraud insurance companies. These are followed by driving license and FIR
related papers.

There is a general perception among customers that the insurance company always
pay less than what you claim for. This usually leads to exaggeration of claims. In
Health Insurance frauds, it often requires co-operation from multiple stakeholders
to organize a fraud.

Though it sounds difficult to get fraudulent documents from Hospitals, or Clinics,
once it happens, it becomes easy to lodge a fraudulent claim. So these days
insurance companies enable various multi-dimensional analysis to identify
fraudulent activities in the shortest possible time, to control claim leakage.
Based on the pattern of analysis, many triggers are set to ensure that fraudulent
claims are not paid.

Q4. What are the triggers to detect fraud claims ?
Ans. There are certain triggers to detect fraud claims. Some of them are :
(i) Treatment costs are usually on the highest side as compared to the etiology.
(ii) Costlier investigations are more.
(iii) Diagnosisoftheailmentandtheinvestigationsdonearenotmuchrelatedto each other.

262 Guide for Health Insurance