Page 364 - Ebook health insurance IC27

The Insurance Times

renewal of the policy, he/she found that a claim has been made in his/her policy
inviting loading of premium from the insurer.
 Claiming for additional services without the knowledge of the patient.

Consumer
With the increasing awareness of the insurance benefits, many policy holders have
got involved in healthcare fraud. Consumer frauds mainly fall in three categories:
 Claim fraud,
 Application fraud, and
 Eligibility fraud.

Claim Fraud
Consumer claim fraud occurs when a consumer makes an intentional
misrepresentation in order to receive a benefit payment he is not entitled for. Such
Claims can be categorized as:
 False claims: e.g. Maternity claims which are not covered under the policy

benefit and member is making a claim of hysterectomy with fabricated medical
papers.

 Collusion with providers to submit false claims: Both provider and the
member collude to submit a false claims where the physician receives the
benefits from the false claims,

 Insurance speculation: An insured applies for several health insurance policies
without revealing his/her other coverages. Insured makes a claim from all
insurance companies.

368 Guide for Health Insurance