Types of Health Insurance Frauds
Deliberate and Opportunity Fraud:
Deliberate Fraud refers to the case wherein a policyholder deliberately, or on purpose, makes a claim by showcasing an accident or loss which is covered by the policy in question. Opportunity Fraud refers to a case wherein the policyholder over-exaggerates a genuine claim, or furnishes wrong details pertaining to pre-existing disease, to get the claim approved.
External and Internal Fraud:
External Fraud refers to a case wherein external parties like the policyholder, medical service providers, beneficiaries, or vendors attempt to dupe the company by making a false claim. Internal Fraud refers to a case wherein the policyholder or the company in question is duped by the manager or the agents.
With increasing awareness and knowledge of the inner workings of insurance policies, policyholders themselves have started reaping benefits from medical insurance scams. Policyholder Frauds can be divided into three categories:
This kind of medical insurance fraud refers to the case wherein the policyholder provides fake information pertaining to his/her pre-existing diseases, employment status, and/or details pertaining to the dependent. It can refer to cases wherein the policyholder submits a claim for a dependent not covered in the policy, or if an employee provides false employment status information to claim benefits, he/she is not eligible for.
This kind of medical insurance fraud refers to the case wherein the policyholder dupes the insurance company by providing information that is false – relating to pre-existing diseases and other vital information.
This kind of medical insurance fraud refers to the case wherein the policyholder files for a claim that he/she is not legally entitled to. These cases often involve ‘fraud rings’ – where the consulting physician, policyholder, and insurer work in collusion. Another case of Claim Fraud can arise when a policyholder purchases multiple health insurance policies and enjoys settlements from all of them.
Consequences of Committing a Health Insurance Fraud
If you are found guilty of participating in health insurance fraud cases in India, you are liable to face the following consequences:
How Insurers Are Fighting Medical Insurance Fraud
Here is how medical insurers in India are lobbying to fight against medical insurance fraud:
Medical insurance fraud is a serious offense in India and can make you liable to incur the above-mentioned penalties if caught in this malpractice. Before purchasing a health insurance policy, make sure you read and understand the fine print pertaining to every single clause of the policy so that you do not knowingly/unknowingly commit a medical insurance scam.
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