Action against fraud
Workings of group 3
Insurance Institute of India, Feb 23-24
Members
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Dr. V Ranjan, KEM Hospital
Amulya Ratna Dash, Reliance General Insurance Co Ltd
Jagbir Sodhi, Swiss Re Services Limited
Surendra Tiwari, Heritage Health TPA Pvt Ltd
Dr. Gayatri V Mahindroo, NABH
Girish Joshi, Birla Sun Life Ins Co Ltd
Ashish Saxena, TTK Healthcare TPA Pvt Ltd
V Madhavan, Royal Sundaram Alliance Ins Co Ltd
Dr. Manoj Gupta, Adroit Consultancy & Sai Lee Hospital
Harsh Jain, L & T General Ins Co Ltd
Prakash P Manuja, New India Assurance Co Ltd
Dr. Hari Hara Sudan, Star Health & Allied Ins Co Ltd
Shobha Ghosh Mishra, FICCI
Rajagopal Rudraraju, Apollo Munich health Insurance Co Ltd
Sorry for any missing names
POINTS DISCUSSED
Current action against fraud
• No Fraud management policy documented
• Action limited to:
– Rejection of claims for serious fraud – all the cases
– Cancelation of policy – in serious fraud cases and not abuse or
mis-declaration
– Most companies do not have an underwriting loop for cases of
mis-declaration and non-declaration
– Action against agents limited
• Legal action against fraud not very common
• Recoveries rare
Legal provisions under IPC
• No specific provisions in IPC for insurance fraud
• Action at best is limited to:
– Section 205. Cheat by personation
– Section 420. Cheating and dishonestly inducing delivery of property
– Section 464: making a false document including signs and seals and
forgery
– Section 405. Criminal breach of trust – suited to life insurance
• All these legal provisions are not adequate to prosecute
an individual legally due of time and cost involved
SUGGESTIONS
Fraud management policy
• Every Insurance company to have a comprehensive Fraud
and Abuse management policy, to contain:
– Definition of types of fraud and abuse
– Policies, procedures and controls to be documented
– Companies action to be documented and inline with severity of
fraud
– Review mechanism
• Fraud and Abuse Management to be a company wide
activity rather than a claims function activity
• Claims, UW, HR, Agency team, legal, operations, etc
Health claims forum
• A health claims forum to be constituted
• Study various local(Life claims council, life UW council)
and global forums to see what can be suitable to us
• Constitution of the committee debated
– Will this just be a Insurer forum?
– Should we include TPA’s and Investigating agencies?
– Should we include other stakeholders?
• Regional forums Vs National forums ?
Sharing of knowledge and data
• It was suggested to share:
– Fraud patterns and case studies
– Fraud customer list
– Fraudulent intermediaries (agents)
– Fraudulent providers including hospitals, doctors, diagnostic
centers, etc
– Fraudulent investigators
• Due legal process to be followed before reporting a case
• External reporting to MCI, IRDA, corporate HR, etc
DISCUSSION