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Health Insurance Fraud

 

“One of our competitors paid our policyholder $3000.00 for a claim that took place in 2013 for malaria, different medical facility.

 

The Claims Manager didn’t know that doctors around the world would write fraudulent documents nor did they have an idea what the usual and customary rates should be in third world countries.

 

I hate to think of how much money they threw out the window over the years.”

 

-      Special Investigator, SIU

Major Canadian insurance company

July 31, 2014

 

travel insurance fraud investigation

Examining foreign health insurance claims from India, the challenges and the way forward

INDIA / GLOBAL – In Ayurveda medicine, the practitioners use oil and massage. Of all the unorthodox medical practices, the most widely-spread in the country is Ayurveda medicine. Although there are establishments that solely render this form of health care, there have been developments whereby orthodox medical establishments, primary, secondary, and tertiary-level hospitals of international standards, those they regard as “super-specialty,” commingle their orthodox practice with Ayurveda practice. This, for foreign insurance companies and underwriters, poses huge challenge in resolving health insurance and medical expenses claims originating from India.


travel insurance fraud investigation

Canadian insurer paid US$12,000.00 for treatment of US$35.00!

 

The fact that the alleged hospitalization was for mere two days indicates the policyholder suffered minor injuries. Inpatients who have major sicknesses or injuries are hospitalized for longer duration or days in sub-Saharan African countries. This is particularly so if the individual suffered injuries. Hospitals in sub-Saharan African countries are not in the hurry experienced in western countries to discharge such patients.


travel insurance fraud investigation

Perennial fraudulent health insurance claimants (1) / Italy

 

Greedy fraudulent health insurance claimants do not simply walk away when caught. Even when each claim is investigated and found inauthentic, they do not stop filing such claims. What they do is to forego the policy and take another policy or series of policies with other insurers. They only hope that one or two of the insurers would not seek on-the-spot investigation and opt to pay the ‘benefits’ straightaway.


travel insurance fraud investigation

Breast augmentation disguised as injuries!

 

Second, for a non-life threatening medical condition, it was a huge red flag that the surgeon proceeded to carry out the operation on the same first day that Mrs. Smith called on him. It appeared difficult to believe that the surgeon was in such a hurry he could not schedule the surgery for another day. Further, it was incredulous that he was able to engage the services of the anesthesiologist and contract the use of the hospital’s operating theater, all on this first visit.


travel insurance fraud investigation

Insights into fraud from South America (2)

 

These days fraudulent claims from Venezuela filed with overseas insurers are mainly those in which the tourists insist on taking a bed at the hospital, usually for the complaint of acute gastroenteritis. They then present the bill to the insurers claiming thousands of US dollars or pound sterling as the equivalent of the local currency for the treatment.


travel insurance fraud investigation

Insights into fraud from Europe (2)

 

Ukraine, as in most of Eastern Europe, is a hotspot of foreign health insurance fraud filed with insurance companies in Europe, the United States and Canada. Often Claims Examiners find it challenging unravelling the fraud. We are aware that some insurers opt to pay knowing full well the claim is bogus.

 

 


travel insurance fraud investigation

Insights into fraud from Africa (1)

 
Nigeria and Cameroon are neighbors geographically.  They also form the “Siamese twins” in regard to fraudulent health insurance claims filed with overseas insurers. It is difficult determining which one trumps the other in volume as well as in complexity. In both countries, over 60% of the claims investigated every year involves those in which the physicians connive with the policyholders to contrive treatment documents when no hospitalization or treatment took place.

travel insurance fraud investigation

Insights into fraud from Asia (1)

 
India and Pakistan form the two major countries where fraudulent foreign health insurance and medical expenses’ claims originate predominantly in Asia. In the years 2011 to 2015, we worked about 50 cases in India for insurers, Health Maintenance Organizations (HMOs) and travel insurance companies in the United States, Canada and Europe. We found out that only two of the cases were authentic while the rest fell into three main categories of fraudulent claims.

travel insurance fraud investigation

Insights into fraud from South America (1)

 
Fraudulent foreign health insurance claims from Colombia mirror the major type pf claims from the entire South American continent, principally, plastic surgical cases. The investigative results often reveal that the policyholder had undergone liposuction or breast augmentation or reduction but disguise it as injuries or another medical condition whose costs are recoverable under their policies.

travel insurance fraud investigation

Insights into fraud from Europe (1)

 
Bodrum, a port city in Mugla Province of Turkey is a tourist and vacation hotspot for Europeans. It is therefore not strange that as in such cities around the world, it has its own share of unscrupulous physicians and medical providers who collude with tourists to contrive medical documents which they present to their insurers on return to their overseas bases. 

travel insurance fraud investigation

The unsophisticated or dumb fraudster (1): The ‘smart’ fraudster was outsmarted by the HMO!

 

We intend to discuss here the unsophisticated claimants in health claims. We regard as unsophisticated claimant someone who leaves so many red flags in his/her claim documentation that a well-experienced health insurance investigator would see so much unreasonableness in the making of the claim.


travel insurance fraud investigation

The Greedy Fraudster: Paid a check for US$24,000.00 but wanted US$39,000.00 and lost all!

This claimant filed two claims with two different health insurers in the United States. Initially, we received the assignment from an investigative agency acting on behalf of one of the insurers. The policyholder claimed that he fell sick on his holiday trip to Nigeria and was hospitalized and treated at a hospital in Abuja, Federal Capital Territory (FCT), Nigeria, in July 1995.