Med insurance fraud on rise
Sector experts say 45% of health insurance claims were found to be fraudulent
COREENA SUARES I DC A number of fraudulent claims have hit the medical insurance sector in the city. Among them, Goodlife Hospital at Kothapet filed six insurance claims all mentioning grastroenteritis and fever or urinary tract infection. Each claim was for about `1 lakh.
Suspecting fraud, insurance investigating officers visited the residence of one of the patients mentioned in the claim and found that he was a doctor working at the same hospital. The signatures were found to be forged.
The investigators called upon another patient, Ms Tripura, wife of one T. Praveen, to ascertain her claim. She gave them a false address. It was later found that she had not undergone treatment at Goodlife Hospital and the documents were fabricated.The insurer filed a police case against the hospital which was later shut down.
Experts said 45 per cent of health insurance claims were found to be fraudulent. Often hospital staff and doctors were involved in the fraud. It included listing an outpatient as an inpatient and replacing genuine patient details with fraudulent claims. Highlighting the kind of fraud they deal with, insurance investigator Chitra Shenoy said a company had received a reimbursement claim from one Sridevi stating that she was admitted at East City Hospital, Neredmet. The investigator found that the hospital had shut down three years back. Another hospital, Akshaya Multi Specialty Hospital, had come up in its place. It said it had no patient called Sridevi.
The claimant had furnished a certificate from Dr P.L. Srinivas who had died long ago, Ms Shenoy said. A visit to Sridevi’s house revealed that her husband Suryanarayana, who runs a medical store, had planned the fraud and had prepared the case sheets of the hospital and Deepthi Diagnostics to avail the medical benefits.
Ms Shenoy said officials found letter pads pertaining to Saluja Nursing Home, East City Hospital, LK Medical Stores and policies of various insurance companies.
The number of hospitals blacklisted by insurance companies is large. An insurance officer told this newspaper that fraud was detected in top corporate hospitals too and the managements were found to be involved.
A corporate hospital in Gachibowli had health insurance cover for its employees. Claims were generated from the employees who were admitted in the same hospital. It was found that the hospital had arranged false bills and claimed insurance.
Insurance investigator Javeed Razvi said, “Most corruption is detected in the reimbursement schemes. Many claimants were not treated at hospitals but claimed insurance as the policy was about to expire. The claimant pays a percentage to the hospital to fabricate bills and raises a claim.”
Even if a hospital is blacklisted, many find ways to relocate to a different region and operate with a different bunch of people. A senior officer from a city-based insurance company said, "Booking a police case is the final step. The police register a case under Section 420 (cheating) of IPC, as there is no designated law. There is a need for a law to stop this menace.” He said insurers were hiring private investigators to check fraud.