Page 262 - Ebook health insurance IC27

The Insurance Times

(B) Frauds During the Contractual Period - During the policy lifecycle, there may
be several transactions carried out by :
(i) Address and Contact Details Change - Care should be taken to check
the address and other details of the customer before the final financial
transaction.
(ii) Sum Assured Alterations - Any increase or decrease of cover needs to be
carefully ascertained and the appropriate disclosures verified.
(iii) Health Checks Undergone - Normally 1% of average sum assured is paid
as reimbursement of Health Check up done after a block of claim free 4
years. Here, the bills and documents should be validated so as to make
sure that the customer has given correct documents.

These transactions could vary based on the nature of product and their permissible
features. Appropriate process control needs to be built so as not to misuse the
system.

(C) Claim Settlement Stage - Claim Settlement is the ultimate testimony for any
insurance company, therefore care has to be taken from the underwriting stage
itself to ease the process. Providing false/misleading information or withholding of
material facts at the time of applying for insurance, making a claim, taking a claim/
payment, making claim for health service not utilized, making multiple claims for
sameillness/injury, altering/destroying/fabricating documents/records are all covered
under this stage. Various fraud scenarios at claim stage are :
(i) Submit the Claim so as to Seek Benefit - Since it involves payment of
benefits of the policyholder, care has to be taken to ensure that the transaction
is done ensuring all checks and controls.
(ii) Provide erroneous Address to Claim Benefit - This type of fraud is done

266 Guide for Health Insurance