Health Insurance Frauds in India

Have you ever wondered how much a fake claim might cost you? In India, health insurance fraud is estimated to drain the system of billions of rupees every year!

Imagine, there is an urgent requirement for surgery to remove a tumour from your brain. You file an insurance claim, hoping for the best. But what if someone else deceit could threaten your access to coverage or even drive up the cost of your premiums? Yeah, in this way a fraud can be directly or indirectly consequential for many people.

Health insurance fraud is a serious problem in India. There are various types of frauds that can trick you and make you lose not just your money but your belief in health insurance. To make you aware of the different types of fraud in health insurance, we have jotted down this article.

Types of Frauds in the Health Insurance Sector

1. Application Fraud

   This fraud includes, knowingly giving false information on a health insurance application. For example, a person goes to buy a health insurance policy but does not disclose a pre-existing condition, to get lower premium rates. This way, he might get the policy, but later he has to face difficulties while making the claim.

2. Claim Fraud

   When the policyholder files a false or inflated claim for medical expenses. Such as submitting the bills of services that you never received, exaggerating the severity of a condition, or even staging a medical incident.

3. Multiple Policy Fraud

   When someone buys multiple health insurance policies from different insurers without informing any of the insurers, and then files claims with each one for the same medical problem. This way, you might get in a huge trouble later on.

4. Billing Fraud

   When the insurer charges you for the services that are not rendered, inflating the charges for services, or upcoming procedures. Meaning, you got a bill for a more expensive service than what was actually performed.

5. Deliberate Fraud

   When someone intentionally deceives an insurance company to get financial gain. The act is planned and purposeful and very different from accidental errors or misunderstandings. In this type of fraud, people usually lie or fabricate the evidence to get the claim.

6. Eligibility Fraud

   When the policyholder misrepresents the information intentionally on the application or during the claim process to gain coverage or benefit. Most of the time, it happens to show eligibility to get the policy or claim. It can related to health history, employment status, number of dependents or anything related to eligibility.

How to Detect Frauds in Health Insurance?

Identifying the red flags of your relationship is not the end, there’s more. Health insurance frauds are major red flags and you should keep an eye out for them too! How you ask? Check out the following points:

Policyholder red flags

• Unusual high number of claims, especially for minor conditions. This can be a sign that someone is trying to exploit the system.
• Discrepancies between the application, medical records and claims. This inconsistent information can raise suspicion.
• Lookout for the claims for services they never received or from the providers they never visited.
• If the claim seems exaggerated for the treatment received, it could be inflated.
• Incomplete or fabricated medical records can be a huge red flag.
• Multiple health insurance policies for the same purpose might be planned fraudulent claims.

Healthcare Provider Red Flags

• Not rendering the bill for the services offered. A classic indicator of fraud.
• Billing for a more expensive service than what was actually performed.
• Recommending unnecessary tests or procedures to drive up the cost and care.
• Frequent billing mistakes might be the intention to get more money from the insurer.
• Claims from a healthcare provider which is no longer in operation could be fraudulent.
• A sudden spike in claims from one particular healthcare provider or location might be suspicious.

Ps- These are just some indicators, and not all instances will be fraud. However, if you suspect something is wrong, it’s important to report it to your insurance company. They have sophisticated systems and investigators to analyze suspicious claims.

Consequences

Committing health insurance fraud can result in a serious web of consequences, impacting you financially, legally, and potentially even medically. Here’s a breakdown of the potential repercussions:

Financial Penalties

Claim Denial- If fraud is detected, your insurance company will likely deny your claim, leaving you responsible for the full cost of medical services.

Policy Termination- Your insurance company might cancel your policy entirely, making it difficult or expensive to obtain new coverage.

Fines- Depending on the severity of the fraud, you could face hefty fines imposed by the legal system.

Restitution- You may be ordered to repay the insurance company any money they lost due to your fraudulent claim.

Legal Repercussions

Civil Lawsuits- Insurance companies may sue you to recover their losses.

Criminal Charges- Health insurance fraud can be a crime, with potential jail time depending on the amount of money involved and the state’s laws.

Impact on Medical Care

Difficulty Obtaining Coverage- A history of fraud can make it very challenging to get new health insurance in the future.

Cash-only Treatment- Healthcare providers may be hesitant to treat you on credit if you have a history of fraud.

FYI- Beyond these direct consequences, there’s also the reputational damage and potential emotional strain associated with being caught committing fraud.

To Sum Up

I am sure after reading about these different types of fraud and how to detect them, you can be a responsible policyholder and help fight health insurance fraud. Remember, health insurance is there to protect you during your medical emergencies. Don’t let someone else’s deceit take away your right to quality healthcare. Raise your voice against this fraud, to safeguard yourself in future. And if you are trying to commit health insurance fraud, it’s crucial to understand the significant risks involved. It’s simply not worth jeopardizing your finances, freedom, and access to future healthcare for a short-term gain. There are many legitimate ways to manage healthcare costs, and exploring those options is far better than resorting to any sort of fraudulent activity.

Health Insurer Network Hospitals