Investigations & Insurance Fraud
Leakages and frauds on account of claim / underwriting will adversely affect the claim experience, which in turn will affect the pricing. Because of the misdeeds of a few and because of the lack of effective control by the Insurance Company, the genuine customers, who constitute the majority, will have to pay higher prices for Insurance Products. In an open market with lot many option available, the consequence are very obvious. Not only because of higher prices it will deter new customer to come – even existing client base will start dwindling. It is, therefore, essential for their own survival that Insurance Companies formulate a claim management philosophy where concern on account of leakages and frauds are taken care of properly.
Property Damage and Theft Claims
Insurance companies will also investigate property damage (e.g., fire damage, water damage or car accidents) and theft claims (e.g., theft, burglary, hijacking or robbery).
Depending on the property and the claim, an investigator might call in an expert. For example, they might ask for someone to come in and evaluate the burn patterns to discover the origin and cause of a fire.
The information gained through this process will help the examiner either confirm or deny that the claim is legitimate.
Healthcare/Medical Fraud Claims
These claims are investigated by private insurers and public ones, such as Medicare and Medicaid. Both the practitioner and the patient can participate in fake or inflated healthcare claims, sometimes together, to line their own pockets.
According to the Legal Information Institute, statistics now show that 10 cents of every dollar spent on healthcare goes toward paying for fraudulent healthcare claims.
retrace HEALTH SERVICES
Claims Investigation is our main competency due to rich experience and knowledge of the health Insurance domain” We are willing to get associated with insurance companies and TPA’s to assist them in identifying those committing fraudulent insurance acts. Our team of highly skilled investigator works closely with our clients conducting insurance claims investigation to prevent fraudulent activities. At retrace, we use many investigation tactics to help Insurance companies/ TPA’s reduce their exposure to deceitful acts of the claimants.
Second Opinion on claim admissibility from Insurance expert and renowned MBBS Doctors We strive to close our cases in the defined TAT.
There is a growing concern among the insurance industry about the increasing incidence of abuse and fraud. It is a matter of concern that insurance fraud is not defined under Indian insurance Act. IRDA recently quoted the definition provided by the international Association of insurance Supervisors (IAIS) which defines fraud as an act or omission intended to gain dishonest or unlawful Advantage for a party committing the fraud or for other related parties. Healthcare fraud as defined by the National Healthcare Anti-Fraud Association (USA) “The deliberate submittal of false claims to private health insurance plans and/or tax-funded public health insurance programs. Intentional deception or misrepresentation that the individual or entity makes, knowing that the misrepresentation could result in some unauthorized benefit to the individual, or the entity or other parties."
As far as Indian market is concerned among all the claims received by the insurance companies 15% are considered to be fraud and its expected that on account of health insurance frauds Insurance companies are losing 600-800 crore annually. Leakages and frauds on account of claim and underwriting will adversely affect the claim experience. Which in turn will affect the pricing. Because of the misdeeds of a few and because of lack of effective control by the Insurance companies, the genuine customer who constitute the majority will have to pay the higher prices for insurance products.