Page 267 - Ebook health insurance IC27

Sashi Publications

past experience, backed by data analytics such that the business coming through
the proper channels are kept on high alerts, so that fraudulence business is not
entering the company books. Sometimes, insurers themselves pick up fraud cases
without any whistle blowing. Based on such proactive sampling investigations,
even the issued policies are sometimes cancelled on suo-moto basis backed by
Sec.45 of the Insurance Act.

(vii) Underwriting/Claim Rules engine & Business Process Transformations -
These days ,most of the underwriting rules and claims rules are built in such a way,
that 80% of generic and genuine claims are proposed automatically. This leaves
sufficient time for the claims managers to analyze the complex and high claim
cases. Business Process Tools also enable the insurers to make quick changes in
the rules.

(viii) Fraud Investigations - A specialized community has nowadays emerged within
the insurance sector with good network across the globe to share various types of
frauds that are happening and also the various new methods of investigations that
are being implemented. This reduces the fraud life cycle and also helps to include
stricter underwriting and claim rules.

(ix) Vigilance Compliance Checks -Vigilance checks, Surprise Audits etc are often
conducted by the company in the premises of the insurance companies and other
stakeholders in search of any fraudulent documents. Actions are then taken
accordingly.

(x) Audits - Frauds are also identified through various types of Audits conducted by
Internal Audit, Risk Audit & External Audit departments.

(xi) Enterprise Risks and Internal Controls - This department oversee all the
processes of the company in a comprehensive manner and check whether all the
processes are available in an integrated manner. The departments continuously

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