Page 265 - Ebook health insurance IC27

Sashi Publications

(i) Welcome calling - Customers after receiving the policies should be given welcome
calls and the various features reiterated. Any untraceable numbers should be
checked with field visits for authenticity.

(j) Plug Process Gaps Quickly - Frauds if not identified and nipped at the bud,
spreads like communicable disease and leaves a greater impact for the
organization. Hence as soon as a fraud is identified , it should be plugged
immediately and adequate measures should be taken not to allow it to repeated
later.

(k) Control Business where Fraud is not manageable - If all the control measures
fail to curb fraud, then a call needs to be taken to stop doing the business in that
format. For e.g, if cash as a mode of payment is leading to many cash defalcations,
then cash payment mode should be stopped.

(l) Feedback to Entities who are Party to Fraud - Sometimes it is difficult to
ascertain whether the party involved has done the same with fraudulent intent,
Therefore, the company must investigate the matter and provide appropriate
warning to all parties concerned/involved. This shall ensure effective control and
sensitization from a future perspective. Many companies have 'malpractice matrix'
which conveys the list of disciplinary actions taken against fraudulent employees.
These have to be agreed upon and signed by the employees before joining the
companies.

Insurance fraud is a serious issue that the insurance companies, law enforcement
agencies andtheindustry regulatorareconfronted with. As health insurancebusiness
is growing fast, leading to an increase in magnitude, complexity and variety of
frauds. To tackle these all the stakeholders need to come and work together to
combat fraud.

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