Important Points for IC 27 - Health Insurance Exam
Page 22 Of 27
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Consumer frauds are mainly categorised in three categories: Claims fund: When a consumer makes an intentional misrepresentation in order to receive a benefit payment he is not entitled to. Application fraud: committed when material misrepresentations are made on an application for insurance with the intent to defraud; Eligiblity fraud: most commonly involves misrepresentation of the status of a dependent or of someones employment status.
Staging of fraudulent claims is a long cycle wherein even there could be no person existing by a specific name at the specific address.
Insurance frauds can be occuring at three broad stages during the policy lifecycle: Fraud possibilities at proposal and policy stage, Frauds during the contractual period, Frauds at claim settlement stage.
The fraud in insurance can be combated through the following combined efforts: Human interface or process improvisation, Technology and process interface.
Doctor seeding is the mystery shopping with respect to the diagnostic centres and doctors wherein the seed will disguise himself as a patient and will tell that he suffers from various diseases and ask the doctor to give a clean chit in the medical examination category of the insurance application form.
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