Page 362 - Ebook health insurance IC27

The Insurance Times

individuals or entities as diverse as medical service providers, policyholders,
beneficiaries, medical consumable vendors, etc.

B) Hard and Soft Fraud
Hard fraud is a deliberate attempt either to stage an event or an accident, which
requires hospitalization or other type of loss that would be covered under a medical
insurance policy.

Soft fraud, which is sometimes called opportunity fraud, occurs when a policyholder
or claimant exaggerates a legitimate claim. Soft fraud may also occur when people
purposely provide false information in regard to the pre-existing illness or other
relevant information to influence the underwriting process in the favor of the
applicant.

C) Provider and Consumer
Fraud can be committed both the insured member or the provider and at times
may be a concerted effort of agents, brokers, insurance employees, insured
member and the provider of services and other stake holders of the health care
system.

Provider:
One of the largest single sources of health care fraud is the health care providers. They
usually have the detailed knowledge of the policy condition, reimbursement process
etc. which makes it very difficult to detect such frauds.

366 Guide for Health Insurance