Types of health insurance frauds in India

Types of health insurance frauds in India


Health insurance sector in India is growing at a fast pace and so are the number of fraudulent claims. Fraudulent health claims i a claim generated to provide wrong information to the insurance company to get the desired health care benefits. As per a leading survey, one in ten claims registered are fraud cases and require through investigation. Health care fraud can be of many types including the ones covered by insurers as well as the insured. Read below about the types of health insurance frauds in India.


  • Claim fraud: This means that the insured is claiming for a health care benefit that he is not entitled to receive as per the policy terms and conditions. In such cases,  the insured and the provider are seen to go for a collusion to benefit the physician. Similarly, a policyholder can purchase different insurance policies from various insurers and make a claim for all.


  • Application fraud: In such cases, the insured aware of all the facts, enters wrong information relating to his pre-existing diseases, date of birth, claims, etc. For instance, policyholder enters wrong date of birth or does not disclose any pre-existing disease to pay less premium, get extensive coverage and have hassle-free claim process. At times, even employers providing health insurance to employees enter wrong joining date of the employees to save on premium.


  • Eligibility fraud: This relates to providing wrong information to the insurance company in terms of insured's employment status, birth date, pre-existing diseases and even nominee. For instance, an employee who is not working full-time for the company and is only working part time can get himself covered in the company health plan by generating false records in company of the HR. 


  • External and internal frauds: External fraud simply means that the false claim is made either by the policyholder, beneficiaries, medical service provider against the insurance company. Internal fraud is carried out by the employees of the company against the policyholder.


  • Deliberate and opportunity fraud: Deliberate fraud is nothing but purposefully presenting the company with an accident, disease or loss which is covered under the policy. Whereas, opportunity fraud is created by the policyholder by providing wrong information on pre-existing disease and over stressing on a genuine claim.


Due to the above frauds, the health insurance sector in India is facing huge losses. The fraud committed either by the policyholder or the company employees is a crime and largely affects the company as well as other genuine policyholders. It is important to understand that fraud registering a claim can lead to cancellation of policy and also land you behind the bars. So always provide all the correct information to the insurance company and choose to buy the policy directly from the insurance company to ensure you are buying from a trusted source. Also, buying policy online offers you discounts, no third party is involved and you have a policy on your mailbox which you can access it anytime.


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