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(iv) Duration of stay in the hospital is more than expected.
(v) Post-operative histopathology reports are not available.
(vi) Documentations are usually in order.
(vii) More member re-imbursement claims from certain providers.
(viii) A pattern where the treating doctor, agents, ailments are the same in many claims.
(ix) Medicine bills in serial order.
(x) Patient residence and the hospital, chemist address, are not geographically same.
(xi) Often short term policy holders with lower sum insured
(xii) Excessive patients per-doctor in a hospital
(xiii) Higher per-patient average visit numbers
(xiv) Higher per-patient average medical tests.

Q5. What type of fraud may be committed by a consumer ?
Ans. Consumer frauds mainly fall in three categories:
(a) Claims Fraud - Claim fraud occurs when a consumer makes an intentional

misrepresentation in order to receive a benefit payment for which he is not entitled.
Such claims are categorized as :
(i) False Claims - These are framed claims. For e.g, if maternity benefit is not

available in a policy, candidate claims for hysterectomy falsely.
(ii) Collusion with providers - When both provider and the applicant colludes

to submit a false claim and shares the benefit with the doctor.
(iii) Insurance speculation - An insured applies for several health insurance

policies without revealing other insurance coverage and claims from all.
(iv) Fraud rings - A group involving consumers, agents, physicians, provider,

etc making false claims.

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