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Action against fraud

Action against fraud. Workings of group 3 Insurance Institute of India, Feb 23-24. Members. 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

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Action against fraud

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  1. Action against fraud Workings of group 3 Insurance Institute of India, Feb 23-24

  2. Members • Dr. V Ranjan, KEM Hospital • AmulyaRatnaDash, Reliance General Insurance Co Ltd • JagbirSodhi, Swiss Re Services Limited • SurendraTiwari, 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

  3. Points discussed

  4. 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

  5. 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

  6. Suggestions

  7. 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

  8. 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 ?

  9. 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

  10. discussion

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