Monday, November 9, 2009

How to control frauds in health insurance claims?

While we have been happy with growth of health insurance segment in the recent years, some of the negative points have started appearing. In the conferences recetly attended by me, I heard the following statements:

1. Insured getting policies issued from 3 insurance companies. Went for hospitalization, managed 3 original sets of bills, reports, receipts, discharge summaries. Lodged claims with all the 3 companies.

2. Hospital having 10 rooms had informed the different Insurance companies/TPA’s that 18 rooms are occupied or say 18 patients are being treated. Bogus names/patients/records are being maintained. Someone jokingly commented that even a software has been developed to handle the bogus accounting.

3. When a hospital was black listed by Insurance co or TPA then they shifted the hospital 4 buildings away with different name and again got listed with Insurance co's /TPA.

4. First floor of the hospital was being used for marriages as a Banquet Hall,with a view to take the benefit of heavy/busy marriage season.

Question before us is frauds have to be controlled as these are adding to the losses of the Insurance Companies and will ultimately result in increase in premium rates.

What are the alternatives before us?

Lodging of FIR with Police-question is then what next?Is it a piece of paper only?

Should these be referred to Economic Offences Wing of the Police Dep’t?

Do we have this specialised wing in all the states?

Should there be black list for those inividuals who are indulging in fraud so that for their life time they will not be able to get Health Insurance Policy? Imagine the data base size? Are all insurance companies ready to share the data?

Identification number to be issued by Authority under Nandan Nilekani should be made compulsory for all proposals /health insurance policies to be issued. As this will take time (may be 3 yrs to cover our population) Then why not start using PAN No as the controlling number.

Comments are invited.

Soon we will have SBI General Insurance Company becoming operational

We understand most of the approvals are through for setting up of JV between SBI and IAG of Australia and in the coming months this company will become operational.
In view of the recent good achievements of SBI Life it is foreseen the competition will increase in Non Life Insurance/General Insurance segment.

Extensive coverage of the branches of SBI all over the country will be a good feature of this company.