{"id":182,"date":"2021-02-16T08:06:00","date_gmt":"2021-02-16T08:06:00","guid":{"rendered":"http:\/\/blog.insurancesamadhan.com\/?p=182"},"modified":"2024-11-02T20:37:08","modified_gmt":"2024-11-02T15:07:08","slug":"health-insurance-frauds-in-india","status":"publish","type":"post","link":"http:\/\/www.insurancesamadhan.com\/blog\/health-insurance-frauds-in-india\/","title":{"rendered":"Health Insurance Fraud Definition, Types, Impact and Ways To Reduce It"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_76 counter-hierarchy ez-toc-counter ez-toc-grey ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">Table of Contents<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/health-insurance-frauds-in-india\/#What_is_Insurance_Frauds\" >What is Insurance Frauds?<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/health-insurance-frauds-in-india\/#Insurance_Fraud_Definition\" >Insurance Fraud Definition:<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/health-insurance-frauds-in-india\/#What_is_Health_insurance_fraud\" >What is Health insurance fraud<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/health-insurance-frauds-in-india\/#Types_of_Frauds_under_Insurance_Sector\" >Types of Frauds under Insurance Sector:<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/health-insurance-frauds-in-india\/#Health_Insurance_Fraud_Examples\" >Health Insurance Fraud Examples<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"http:\/\/www.insurancesamadhan.com\/blog\/health-insurance-frauds-in-india\/#How_to_Prevent_Fraud_in_Health_Insurance\" >How to Prevent Fraud in Health Insurance?<\/a><\/li><\/ul><\/nav><\/div>\n\r\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"What_is_Insurance_Frauds\"><\/span>What is <strong>Insurance Frauds<\/strong>?<span class=\"ez-toc-section-end\"><\/span><\/h2>\r\n\r\n\r\n\r\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Insurance_Fraud_Definition\"><\/span>Insurance Fraud Definition:<span class=\"ez-toc-section-end\"><\/span><\/h3>\r\n\r\n\r\n\r\n<p>Fraud in Insurance is an Act or omission intended to gain the dishonest or unlawful advantage for a party committing the fraud or for other related parties. Similarly in Abuse, people indulge in activities that are inconsistent with business ethics and medical practices which results in an unnecessary rise in claim costs. Unfortunately, there are many different types of Insurance frauds in India but let me today explain to you one of the most common subsectors of frauds in India- Health Insurance Frauds.<\/p>\r\n\r\n\r\n\r\n<p>Fraud in insurance can take any form and can be committed in a variety of ways. It is wilful and deliberate, and done for illegal financial gain. It can be committed by any party involved in insurance related activities. Fraud is an increasingly serious matter as insurance business depends on trusts and keeping promises. The ultimate objective of the Insurance is to provide protection for all. Where fraud occurs, both Insurance Company and Policyholders bear the losses. Fraud goes against all the basic principles of insurance such as insurable interest, utmost good faith, proximate cause and indemnity. \u00a0Therefore, Fraud will hit back at the customers with unaffordability of premiums and consequently affect their protection levels.<\/p>\r\n<center><a href=\"https:\/\/www.insurancesamadhan.com\/register\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" src=\"https:\/\/www.insurancesamadhan.com\/assets\/img\/contact.png\" alt=\"Get Resolutions for Insurance Complaints\" \/><\/a><\/center>\r\n<p>&nbsp;<\/p>\r\n\r\n\r\n\r\n<p>Let\u2019s begin with the basic understanding of What is a Health Insurance Fraud?<\/p>\r\n\r\n\r\n\r\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"What_is_Health_insurance_fraud\"><\/span>What is <strong>Health insurance fraud<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\r\n\r\n\r\n\r\n<p>Health insurance fraud can be clarified as a circumstance where an insured or medical service provider furnishes fraud, false or misleading information to the insurer with the intention to achieve out of line profits from a policy for the policyholder or service providing source.<\/p>\r\n\r\n\r\n\r\n<p>Abuse describes practices that, either directly or indirectly, results in raising the costs. It refers to practices not consistent with providing patients with services that are medically necessary, or that fail to keep the relevant professional standard, or where prices are charged unfairly. In Health Insurance, Abuse can be excessive diagnostic tests, extended and unnecessary stay in Hospital. Conversion of an outpatient or day care procedure into Hospital Admission, admission in Hospitals limited to diagnostic investigations.<\/p>\r\n\r\n\r\n\r\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Types_of_Frauds_under_Insurance_Sector\"><\/span><strong>Types of Frauds under Insurance Sector:<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\r\n\r\n\r\n\r\n<p>The Insurance Regulator IRDA has categorized health insurance frauds into the following types-<\/p>\r\n\r\n\r\n\r\n<ul class=\"wp-block-list\">\r\n<li><strong>Claim fraud:<\/strong>\u00a0Fraud against the Insurance Companies in the purchase and\/or execution of an insurance product, including fraud at the time of making a claim. In other words, this means that the customer is claiming for a health cover that he\/she\/they may not be entitled to as per the terms and conditions of their policy.<\/li>\r\n<li><strong>Application Fraud:<\/strong>\u00a0Here,\u00a0the customer despite being\u00a0aware of\u00a0all factual information related\u00a0to his pre-existing\u00a0diseases, conditions,\u00a0 DOB, claims, etc enters the\u00a0wrong information. In other words, policyholders do not disclose pre-existing conditions (such as diabetes) to save on premiums and get more coverage. There are also certain scenarios where we have come\u00a0across many agents\/insurers encouraging customers\/policyholders to not disclose such diseases or enter false information to pay fewer premiums.<\/li>\r\n<li><strong>Eligibility Fraud:<\/strong>\u00a0This also denotes fraudulence by providing false information. For example, providing the wrong employment status of the employee in order to gain eligibility to a health policy with extra benefits. In other words, let\u2019s say an employee who is only working part-time generates false records of his\/her\/their employment status to stand eligible for the company\u2019s health cover.<\/li>\r\n<li><strong>Medical Identity Theft:<\/strong> Here, a policyholder\u2019s name is being wrongly used without the consent or knowledge of the person to access free medical services or treatments. In such scenarios, false insurance claims are submitted in order to gain free services.\u00a0 This leads to false information being added to the policyholder\u2019s medical records.<\/li>\r\n<li><strong>External and internal frauds:<\/strong>\u00a0Simply put, external fraud refers to fraudulence made either by the customer, service provider or beneficiaries against the insurance company. Whereas internal fraud is made by agents or insurance companies against the customer.<\/li>\r\n<\/ul>\r\n\r\n\r\n\r\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-4-3 wp-has-aspect-ratio\">\r\n<div class=\"wp-block-embed__wrapper\">https:\/\/www.youtube.com\/watch?v=BzGNGvDjOz8<\/div>\r\n<\/figure>\r\n\r\n\r\n\r\n<p><strong>Also Read:<\/strong> <a href=\"https:\/\/www.insurancesamadhan.com\/blog\/benefits-of-health-insurance-policy-in-india\/\">Top 10 Benefits of Health Insurance Policy in India<\/a><\/p>\r\n\r\n\r\n\r\n<p>Let me present you with more examples of the different types of health insurance frauds<\/p>\r\n\r\n\r\n\r\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Health_Insurance_Fraud_Examples\"><\/span><strong>Health Insurance Fraud Examples<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\r\n\r\n\r\n\r\n<ol class=\"wp-block-list\" type=\"1\">\r\n<li>Treatment of uninsured persons, but billing for insured persons covered in the health policies.<\/li>\r\n<li>Billing for Doctor Fees for his unnecessary visits to the patients in the Hospital.<\/li>\r\n<li>Billing for services not rendered.<\/li>\r\n<li>Unwarranted procedures, excessive investigations, expensive medicines.<\/li>\r\n<li>The extended length of stay keeping in view the high sum insured in the policy.<\/li>\r\n<li>Documents submitted are of doubtful nature.<\/li>\r\n<li>Claims for disease or injury which seems to be pre-existing.<\/li>\r\n<li>Collecting treatment cost from the innocent patients with misrepresentation that all amounts will not be admissible in an insurance policy.<\/li>\r\n<li>Filing claims for treatments that are not medically necessary.<\/li>\r\n<li>Intermediary takes the premium but does not pass it to the Insurance Company.<\/li>\r\n<li>Intermediary inflates the premium and passes the correct premium to the insurance company and keeps the difference.<\/li>\r\n<\/ol>\r\n\r\n\r\n\r\n\r\n\r\n<p>The remedies for Fraud across the insurance value chain include Compliance with the procedure of KYC, Pre-Medical check-ups, Timely Renewals and better services by the insurance industry. The IRDA has also issued guidelines that all insurance companies registered in India are required to have in place an Anti-Fraud Policy duly approved by their respective Boards.<\/p>\r\n\r\n\r\n\r\n<p>Now that you know everything- in and out around health insurance frauds, let me now tell\u00a0 you the various ways in which you can prevent health insurance frauds.<\/p>\r\n\r\n\r\n\r\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"How_to_Prevent_Fraud_in_Health_Insurance\"><\/span><strong>How to Prevent Fraud in Health Insurance?<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\r\n\r\n\r\n\r\n<p>The following corrective measures to be taken to have control on Fraudulent Health Claims.<\/p>\r\n\r\n\r\n\r\n<ul class=\"wp-block-list\">\r\n<li>Carefully read your health insurance policy\u2019s terms and conditions<\/li>\r\n<li>Carefully fill in the application and enter all requested details honestly and correctly.<\/li>\r\n<li>Immediately get in touch with the insurance company if you suspect fraud.<\/li>\r\n<li>Ensure to thoroughly read all\u00a0 \u2018add-on\u2019 benefits that you are entitled to.<\/li>\r\n<li>Identification of Hospitals committing frauds.<\/li>\r\n<li>Identification of Intermediaries indulged in fraudulent activities.<\/li>\r\n<li>Compliance with the procedure of KYC for premium and settlement of claims.<\/li>\r\n<li>Beware of \u201cfree\u201d offers<\/li>\r\n<li>Closely review all your medical bills<\/li>\r\n<\/ul>\r\n\r\n\r\n\r\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\">\r\n<div class=\"wp-block-embed__wrapper\">https:\/\/www.youtube.com\/watch?v=Oy8LkhxQT3U&amp;t=57s<\/div>\r\n<\/figure>\r\n\r\n\r\n\r\n<p>If you are facing any problem while buying health insurance for yourself or your family you can contact Insurance Samadhan, our insurance experts are always ready to help you.<\/p>\r\n\r\n\r\n\r\n<p>To reach us at InsuranceSamadhan.com \u2013<\/p>\r\n\r\n\r\n\r\n<p>Call us at \u2013 844 844 0626<\/p>\r\n\r\n\r\n\r\n<p>Mail us at \u2013\u00a0<a href=\"mailto:corporate@insurancesamadhan.com\">corporate@insurancesamadhan.com<\/a><\/p>\r\n<center><a href=\"https:\/\/www.insurancesamadhan.com\/register\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" src=\"https:\/\/www.insurancesamadhan.com\/assets\/img\/contact.png\" alt=\"Get Resolutions for Insurance Complaints\" \/><\/a><\/center>","protected":false},"excerpt":{"rendered":"<p>What is Insurance Frauds? Insurance Fraud Definition: Fraud in Insurance is an Act or omission intended to gain the dishonest or unlawful advantage for a party committing the fraud or for other related parties. Similarly in Abuse, people indulge in&hellip; <a href=\"http:\/\/www.insurancesamadhan.com\/blog\/health-insurance-frauds-in-india\/\" class=\"more-link\">Continue Reading <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":183,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_uag_custom_page_level_css":"","footnotes":""},"categories":[3],"tags":[],"class_list":["post-182","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-health-insurance"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.8 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Health Insurance Fraud Definition, Types, Impact And Ways To Reduce It<\/title>\n<meta name=\"description\" content=\"Health insurance fraud involves deceptive practices to gain unfair benefits, impacting costs. 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