Page 263 - Ebook health insurance IC27

Sashi Publications

by siphoning the policyholder's money where the address is changed just
before the claim is initiated. To control such incidents, there are checks
which the companies have put in place and important one being KYC
document check before claim payment.
(iii) Inflation of Medical Bills/Extended LOS - This is the most common fraud
in health insurance,. Here, because of the strong nexus between the provider
and thecustomer, it becomes difficult for the insurance companies to manage/
control fraud. The reason often being - Nature of documentation is made
appropriate , Tariff charts are not well defined and there is a good amount
of subjectivity, in defining the medical necessity/protocol. IT is due to the
complex nature of Health insurance schemes, that it becomes quite difficult
to control and check fraudulence.

Q7. Explain how frauds can be combated through human interface or process
improvisation.

Ans. Frauds can be combated through various Human Interface or Process
Improvisation steps. They are as follows:

(a) Creation of a Fraud Database - This provides Information on frauds , comprising
of customers, agents, service providers and doctors. This database serves as a
powerful tool, not only at the claim settlement stage, but also at the time of
underwriting. Such database should be constantly updated, extended and integrated
with other financial services. However, all frauds should not be judged only on the
basis of fraud database, but other techniques should also be used.

(b) Create Consumer Awareness - The toughest challenge is to educate the insuring
public on the evils of insurance fraud and ways to prevent it. A sustained campaign,
similar to the ones released by the IT Dept to combat tax evasion, or RBI on not
sharing bank details, is required to sensitize the average insuring public. Only

Website : www.bimabazaar.com, PH: 033 22184184/40078428 267