INSURANCE FRAUD

HEALTH INSURANCE FRAUD

Health insurance represents an important class of insurance policy to look out for. It helps you to pay for your health care needs s they arise. It may covers services that ranges from normal hospitals visits or doctor checks to serious illnesses. And it may also cover preventive health care services to keep you and your family healthy. The payment of your premium for health insurance coverage to your insurer will guarantee coverage to you and your family members depending on your agreement. It is equally possible that you will have to pay a fraction of your health care services bills whenever you receive medical attention. In this article, we will discuss whether non disclosure of health insurance to hospital amounts to health insurance fraud or not.

MEANING OF INSURANCE FRAUD

Insurance fraud is any act done so as to take undue advantage of an insurance process. It occurs when claimant attempts to obtain a benefit or advantage which is not due to him. As well as when an insurer attempts to deny some insurance benefit due to a claimant.

IS NON DISCLOSURE OF HEALTH INSURANCE TO YOUR CLINIC A FRAUD?

Now, the essence of this article is to ascertain whether it is a fraud if you don’t disclose your health insurance to clinic. To this, every insurance company have its rules and ways regarding the assessing of your health insurance based medical services. They equally as always, set the limitations as to the level of care you will access and sometimes, limitations as regards where you will access your medical attention, maybe, at a specific clinic or hospital or that you have to be attended to by a specific medical doctor.

Generally, it is expected of the policyholder to avail the hospital details of information concerning his health insurance policy each time he visits the hospital for services. The essence is to enable the hospital bill the insurance company for the medical services which you have accessed. The information contained in your insurance card proves on the face of it that you have health insurance with the company in question. It equally contains information which your health care provider will use to claim payment from your insurer. And to do this, the hospital will usually make a copy of your insurance card.

Moreover, hospitals and insurance companies often enter into agreement that spells out the amount of payment due to them from a medical care given to their policyholder. This limitation is always of help to the policyholder as it enables him know the amount he would pay out of his own pocket which is always little.

 The implication of not presenting your insurance card to the hospital is that you have to pay out of your pocket to receive medical attention in the coverage of your insurance policy.

Consequently, it is safe to conclude that it is not insurance fraud if you don’t present your insurance policy card to the hospital. Moreover, you still have the chance to apply for reimbursement from your insurers. But it must be within a year of receiving such treatment or medical services.

CATEGORIES OF PERSONS WHO MAY RECEIVE HEALTH CARE SERVICES WITHOUT PRESENTING HEALTH INSURANCE CARD

They are still categories of persons who can benefit from a medical insurance policy without having to present a health insurance card, some of these includes;

1. Youths who are of ages between ages 14 to 17 who consult a doctor without their parent s authorization
2. Underage children who do not own a card but make use of that of their parents
3. Patients who require urgent medical attention or care
4. Persons who live at rehabilitation centres

TYPES

Insurance fraud can broadly be classified into two categories and they include; 1. Internal insurance fraud and 2. External insurance fraud.

INTERNAL INSURANCE FRAUD

Internal insurance fraud occurs when insurance agents defraud insurance companies and policyholders. Examples include:

1. Fake insurance documents. This occurs when insurance agents issue fake policies and certificates and even fake insurance identification cards.
2. Embezzlement of premiums. This occurs when insurance agents and brokers receive insurance premiums for insurers without remitting same to them. And sometimes goes ahead to issue fake insurance certificates or even none at all on the basis of the said embezzled premium.
3. False statements. This occurs when insurance agents issue fake policies and certificates while filling documents with government agencies.

EXTERNAL FRAUD

External insurance frauds are mainly ones perpetrated against insurance companies by individual policyholders, health care providers, beneficiaries of insurance policy etc. examples of external insurance fraud includes;

1. Creation of fraudulent claims. This type of external insurance fraud may include, faking death in order to claim insurance benefits or filling a phony death claim. Phony burglary or theft or vandalism, staged homeowner burglary or accident, staged auto accident or even murder for profits etc.
2. Exaggerated claims. This occurs when policyholders or beneficiaries overestimate their amount of loss they sustain. It may also occur in the form of inflating the value of loss during robbery. It may also be in the form of inflating bodily association from an auto accident and so on.
3. Medical fraud. Insurance health care providers can collude with patients to create a inexistent accident related injuries in order to make claims. The hospitals with these schemes usually charge insurance companies for inexistent medical care.
4. Property fraud. This occurs when a property owner fraudulently buys plenty insurance policies in respect of same property. And in the event the property sustains damages, the property owner proceeds to claims benefits from all the policies.
5. Disaster fraud. Unscrupulous operations often lure victims of disaster to claim more damages that actually occurred or even claim monies to repair damaged properties which are never done.
6. Falsifying theft reports. This occurs when a property owner falsely reports stolen items or even exaggerates the monetary values of the stolen items I order to claim undue insurance claims from an insurance company