Page 261 - Ebook health insurance IC27

Sashi Publications

wording of the questions should be written in such a way so as to elicit
maximum information.
(b) Disclosure of Material Information at the Medical Stage - Normally,
Insurers seek additional information about the insured's health by asking for
a health check up, usually done on the basis of age, size of sum insured or
doubt/suspicion from the application form. The medical check up is usually
done by an empanelled doctor/ empanelled centre. This helps the insurer in
identifying theanyadversity/abnormality, estimatetheprognosisoftheailment
and hence price the risk correctly. The following disclosures have to be
appropriately studied :
(i) Disclosure of Health Status - If anyone is suffering from hypertension or
diabetes, and is under medication, it becomes difficult to know about it.
These frauds potentially penalize the genuine policyholders.
(ii) Impersonation - To avoid this , the applicants need to carry a valid and
authentic photo id proof to be shown before the examination, to ensure that
the applicant is the right person. There are instances of low cost policies
done for servants and other known persons. Close monitoring is needed to
detect such acts and severe penalties need to be imposed.
(iii) Manipulation of Tests/Records - In addition to the manipulation done by
the agent or customer, even the medical doctors could be a party to insurance
fraud and provide manipulated test results to suit the insured's requirement.

(c) Cash defalcation - Another most widespread fraud at the proposal
submission and at renewal payment stage is cash defalcation. Though several
measures are being taken to restrict cash transactions, no company has
been able to nip it off completely.

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