Important Points for IC 27 - Health Insurance Exam
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Judicial channels where complainant can approach: District forum: Established by State government in each district, State Commission: Established by State government in a state, National commission: Established by Central government by notification.
Health insurance fraud is described as an intentional act of deceiving, concealing, or misrepresenting information that results in healthcare benefits being paid illegitimately to an individual or group.
Whether claim money is paid or not, fraud has its impact in various dimensions on the insurance industry: If the claim is paid, then it affects the claim ratio, chargeable premium and acturial pricing which in turn affects the reinsurance ratings and triggering more stringent underwriting norms that may cause aversion among the genuine public to take policies with the company; Similarly, if the claim is not paid also, it has multiple effects due to spread of news regarding higher repudiations which in turn may affect business and also the faith in the industry.
Frauds are classified as: Internal and external, Hard and soft, Provider and consumer.
Motor and health insurance are very much prone to insurance related frauds. In health insurance frauds, it often requires co-operation from multiple stakeholders to organise a fraud.
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