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HEALTH INSURANCE FRAUD

Contents

What is the health insurance fraud?1

2

Who easy to get insurance fraud?3

Conclusion4

Which kind of health insurance fraud?

WHAT IS HEALTH INSURANCE FRAUD?

Health insurance fraud means that the customers intend to get incorrect benefits more than sum assured that customers should have gotten.

We concentrate in: Cathay Accident Medical Rider (R03)Cathay Child Accidental Rider (R02)Cathay Medical Rider (R04)

THE COST

The cost of Fraud is impossible to quantify Based on AIMA (The Academy of Insurance

Medicine of Asia) conference, the large sum was loosen by health insurance fraud: In USA, they estimate form 68$ to 175$ billionIn Saudi Arabia: 320$ million

THE COST & LOSS

As report in AVI (association of Vietnamese insurers) meeting in 2009, every year one big insurer company had to paid billions VN dong for Hospital rider.

The claims for hospital benefit in the North are higher than others many times.

The claims for hospital benefit at Ha Noi & HCM are always low.

Top 4 common diseases occupied 1/3 total claim cases: joint pain, bronchitis, virus infection & eye diseases.

WHAT KIND OF THE FRAUD?

Dishonestly makes a false representation Hospitalize several times in a short period

with nonsensical reason. Submit false documents. Stay at the hospital too long more than

necessary to treat one simple disease.

WHO EASY TO GET INSURANCE FRAUD

10% of people- inherently honest

10% - inherently dishonest

80% of people could be influenced either way

WHO EASY TO GET INSURANCE FRAUD

Unemployed, retired Housewife, househusband Children Teachers Medical staffs Workers Agents

EXAMPLE

Hospital abuse:

At Điện Biên province (in the North), one company bought hospital rider for 18 staffs with highest sum assured.

Every staff had claims with common diseases: back pain, joint pain, red eye, vertigo, average 3 times/year.

The investigator found that agent is vice president’s wife and relative of staff of a hospital.

Timekeeping record showed that they were present at the office within the hospitalization period.

EXAMPLE

False document:

One hospital at Quang Nam province, in 2007 & 2008 there are increase number of hospital claims with complete documents as medical report, discharge note, invoice….

The investigator found that life assured didn’t know anything about their hospitalization.

Agents cooperated with high rank of medical staffs & FA at local hospital.

CONCLUSION

Have a closely term & condition Train professional ethics to agents Underwrite with clear-headed Handle claim wisely, note & follow up any

sign of insurance fraud, cooperate with UW to review or adjust regulation.

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