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Managing Service Operations

In: Business and Management

Submitted By ayush7291
Words 1054
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The presence of fraud in the insurance industry is not an unknown one. Health insurance seems to have large number of these fraud cases. A larger point of concern is that as per statistics, 90% of the insurance frauds come from health policies itself. Since the key motive for every fraud is financial profit, there are no exceptions to the people who are involved in it. The involvement of these people in these cases could range from the customer, to the agent, member of hospital in question, or even the employee of the insurance company itself.
COMMON OCCURRING FRAUD IN THE INDUSTRY
Health frauds can be broadly divided into hard frauds and soft frauds. Each of these categories consists of situations ranging from misinterpretation of facts, to fabrication of documents, and even situations including inflation of claims. Here are some of the malpractices that the industry comes across: * Misrepresentation of facts: This is one of the largest frauds; a case qualifies as misrepresentation when the applicant is completely aware of inaccuracy of the statement provided. The most commonly falsely stated details are regarding the details of medical condition, incorrect personal details such as name, age, identity or even information such as medical history, past claim information and so on. * Fabrication of documents: It is commonly noticed that it often acts as frequent form of fraud related activities that the industry is facing now a days. These documents range from those regarding medical details, or documents at the later stage such as claims related or other documents as fake letterheads. Forgery of medical bills and receipts is yet another increasingly rampant issue in health insurance frauds. * Inflation of claims: Another frequent occurrence in the domain of insurance is the inflated claims. It is not rare to come across the assumption by the customer…...

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