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ICICI Lombard Expert Blog
 

Health Insurers to Share Data on Fraudulent Claims

August 15 2017
Health Insurance Fraud Claims

The General Insurance Council (GI Council) is the governing body representing the collective interests of all the non-life insurers in the country.

The council has therefore written to health insurers, to share data on claims that they suspect are fraudulent. The move has has been approved after an effort of more than two years by the council which only culminated in health insurers seeing the benefit of collaboration and in weeding out cases where medical establishments and healthcare providers, inflate or create medical bills specifically to claim health insurance.

This letter was marked to 28 insurance companies, which encompass health insurance within their portfolio. The communication also states that the insurer shall share details of its investigation and provide documented proof to the council of the healthcare providers, when it suspects healthcare providers of facilitating fraudulent transactions.

Once the insurance company collates and sends this data, the GI Council forms a screening committee comprising of five members from various insurance companies to evaluate the possibility of a fraud. After screening the case, the committee raises a red flag against the medical establishment; if suspected of fraud, for the matter to be referred to a health strategy group to be formed by the Council.

The whole purpose of forming these committees is to identify patterns that are a hallmark of such cases and share it with the insurers, thus making it easier for them to detect and blacklist offenders. However, the council has clearly stated that, even though the option of registering a police case is open, they would rather use that measure as the last resort.

This anti-fraud measure could not have come at a better time. The government has been promoting health insurance for the masses, especially the poor, for quite some time now. This is where misselling of health covers have become the leading cause of concern for the government.

The risk is huge as the general insurance industry is growing at breakneck speed, with health insurance as the second largest portfolio, after motor insurance. Till the month of May 2017, collection of general insurance premium rose by 15.95 per cent, within which health insurance saw a rise of 13.1 per cent. This step by the GI Council is the first of its kind in the insurance space and a similar measure is also being planned for motor insurance portfolio.

Source: Bimabazaar

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