THIRUVANANTHAPURAM: Policyholders often have a love-hate relationship with medical insurance companies, particularly when it comes to claims. However, in a reverse scenario the insurance companies are increasingly concerned about rising instances of high-tech frauds involving forged documents in medical claims.
Among the culprits are individuals from diverse professions, including a techie working for a multinational company, a naval contractor, an accountant, and even a doctor involved in forging documents.The techie, hailing from Ernakulam, was caught with the help of a Third-Party Administrator for submitting multiple claims using fraudulent medical documents in the names of several relatives.
“The employee was based in the UK when he made the online submissions. Upon notifying his employers, he was recalled and dismissed from his position,” said Dr Ushus Kumar, Director of Optimus Medical Services Pvt Ltd, the company that investigated the case. The investigation also uncovered another fraudulent scheme involving a naval contractor from Ochira, who exploited online pharmacy bills to claim post-hospitalisation expenses.
He had submitted a claim of Rs 3.4 lakh after receiving heart treatment at a hospital in Karunagapally, covered under Niva Bupa Health Insurance. By ordering medicines from online pharmacies like PharmEasy and Netmeds, then cancelling the orders, he presented these false bills to make claims. “His purchase patterns raised red flags with the pharmacies, which subsequently alerted the insurance company. We also found that he had defrauded another insurer in a similar way,” Dr Kumar added.
In addition to individual fraudulent claims, investigations have also uncovered fraudulent activities by shell companies offering group insurance. “A former accountant at a timber company in Malappuram included his family members in the group insurance policy without the owner’s knowledge. Similarly, we found a man in Thrissur who misused a Hospital Cash Insurance policy, which provides a fixed sum for each day of hospitalisation.
He claimed money from multiple insurance companies,” said the managing director of another insurance investigation service. His company is currently investigating a “phantom billing” case involving a hospital.
Insurance companies claim that such frauds often go undetected because claims processing is sometimes handled by random units. According to the Insurance Institute of India, it is estimated that insurance companies lose around Rs 600-800 crore annually due to fraudulent healthcare claims.
As the volume of fraud increases, companies are relying on multiple service providers to help identify fraudulent activities. However, lawyer and consumer rights activist A D Benny argues that frauds against insurance companies are relatively minor compared to the widespread mis-selling carried out by unscrupulous agents.