In Global Insurance Fraud Education (GIFE) we offer lessons on how to combat life, health, and travel insurance frauds originating around the world. This link is an extension of this effort. Here, we discuss salient case notes from which the practitioner can gain immediate insights and thus improve on their professionalism. If they are positively impacted that they have a better understanding of their work, then we can clink glasses that our objectives are accomplished.
Anti-Fraud Training
Calling on Polytechnics and Universities!
GLOBAL – A more pragmatic approach to training people from the polytechnics and universities should be adopted and encouraged. Towards this, we will be calling on every polytechnic and university offering higher diploma and degree programs respectively in insurance to incorporate the fraud courses in their curriculum. We have developed the coursework, Global Insurance Fraud Education (GIFE) Program, for the academic community and the global insurance industry. The coursework could be offered as a certificate program and could be expanded and taught as a degree program.
The many readers of an insurance investigation report!
GLOBAL / REPORT WRITING – Many Insurance Investigators believe that their reports are read or are for use by only the Claims Examiner or the principals who engaged them on the task or assignment. They are wrong! Whether your principal is an insurance Claims Examiner or an investigative agency acting on behalf of an insurance office, the insurance investigation report has many audiences or readers. The insurance investigation report is read by the following:..(6) Judge and Jury…
Uncovering Fraud from Patients’ Register!
GLOBAL – We have noted that in some cases, physicians had superimposed the policyholder’s name on an existing name or erased a previous name with white fluid. They may also draw a line across a previous name in the register and then insert the policyholder’s name at the top.
Life Insurance Fraud
Interviewing the family is a sine qua non to uncovering fraud
The trend these days with life insurers’ Claims Examiners and Special Investigators is
for field investigators not to conduct inquiries with the claimant’s family members. Often, the insurers are inundated with requests by claimants that they do not want their family to be contacted by the Investigators. The excuse they readily offer is that they do not want their family to know there was a life insurance on the deceased family member.
Emergency Medical Expenses |
Medical Tourism
Intelligence work saved insurers US$100,000!
The insurers were clearly perplexed and genuinely worried. They instructed us to conduct on-the-spot investigation in Bangladesh to establish if there had been pre-existing history for the condition or not. Also, to find out if there was any documentary evidence that either the policyholder was aware of the condition prior to leaving Bangladesh or even better, had received treatment for the same before leaving for the United States.
Accidental Death Fraud
The conniving pathologist!
What was apparent on this case was that the aged policyholder possibly died of complications from a medical condition unrelated to an accident or following injuries sustained in a motor vehicle accident. However, since she was covered under an accidental death policy, which provides payment of benefits if death occurred accidentally, it became imperative to seek officials of the Police and the pathologist to contrive a “police report” and a “post-mortem report” respectively.
Travel Insurance Fraud |
Emergency Medical Expenses |
Medical Tourism
Pre-planned treatment / Medical tourist countries, Case 2
Ecuador has become an emerging tourism destination for citizens of the United States and the United Kingdom. One such a claim we investigated in the country for a United Kingdom insurer is highlighted here. This is our continuation to further explain medical tourism to the members.
Health Insurance |
Emergency Medical Expenses
Examining foreign health insurance claims from India, the challenges, and the way forward
In Ayurveda medicine, the practitioners use oil and massage. Of all the unorthodox medical practices, the most widely spread in the country is Ayurveda medicine. Although there are establishments that solely render this form of health care, there have been recent developments whereby orthodox medical establishments, primary, secondary, and even tertiary-level hospitals of international standards and those they regard as super-specialty, commingle orthodox practice with Ayurveda practice.
Travel Insurance Fraud |
Emergency Medical Expenses |
Medical Tourism / Facilitator Explained
Pre-planned treatment / Medical tourist countries, Case 1
The Director did not immediately realize the full implications of the card he presented to us. It was a clear confirmation he had acted in his capacity as a Medical Tourism Facilitator to the hospital in respect of Mr. Yeshiva even though he was not willing to state it in writing. We then commented that his card had clearly shown that the treatment of Mr. Yeshiva was pre-planned or pre-arranged by them before he embarked on the trip from Europe.
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