Guide On Fraudulent Health Insurance Claims in India
Close
Close

Buy a Life Insurance Plan in a few clicks

Now you can buy life insurance plan online.

Kotak e-Term Plan

Protect Your family’s financial future with Kotak e-Term Plan. Know more

Kotak Assured Savings Plan

A plan that offer guaranteed returns and financial protection for your family. Know more

Kotak Guaranteed Savings Plan

A plan that offers long term savings and insurance in one premium. Know more

Kotak e-Invest

Insurance and investment in one plan with Kotak e-Invest. Know more

Close

Get a Call

Enter your contact details below and we will get in touch with you at the earliest.

  • Select your Query

Thank you

Our representative will get in touch with you at the earliest.

Kotak e-Term Plan

Guide on Fraudulent Health Insurance Claims in India

One in every ten insurance claims are fraud cases. Here is a guide on different types of health insurance frauds, read the article to know more about frauds.

  • Aug 27, 2021
  • 644 Views

Even though the Indian Insurance Act or the Indian Penal Code does not have specific laws for ‘insurance fraud,’ it has been known to occur in India, either by policyholders, intermediaries or employees of the insurance provider. When insurance fraud occurs in India, the sections of the IPC that deal with fraudulent acts and forgery are applied.

Let us understand what exactly comes under the purview of health insurance claims fraud.

What is insurance fraud?

The Insurance Regulatory and Development Authority of India (IRDAI) used and quoted the definition of insurance fraud as said by the International Association of Insurance Supervisors (IAIS), which is “an act or omission intended to gain dishonest or unlawful advantage for a party committing the fraud or for other related parties.”

Types of Fraud

The IRDAI has classified insurance fraud into the following three categories:

  • The policyholder or Claims Fraud
  • This can be defined as a fraudulent activity carried out by the policyholder against the insurance company either during the purchase of the policy or during executions of the policy. This could include providing inaccurate information in the application form or not disclosing information relating to health status or income. Frauds committed at the time of making a claim also fall under this category.

  • Internal Fraud
  • When the fraud committed is carried out by a staff member or employee of the insurance company against the insurance company themselves, it can be termed internal fraud. This can include misappropriation of funds and other frauds.

  • Intermediary Fraud:

When an agent or intermediary commits fraud against either the insurance company or the insured policyholder, it is called intermediary fraud.

Most Common Claims Related Frauds

Most frauds are committed during the claims process by policyholders. The following are some common examples of Policyholder or Claims Frauds.

  • Hiding Pre-existing Diseases and Conditions
  • This is the most common health insurance fraud. Policy buyers tend to withhold information related to their pre-existing conditions in their application forms. Since there is a waiting period of two or three years for pre-existing conditions and the premium may also be higher, applicants tend to hide this fact. They can also manipulate the results of the pre-policy health evaluation to conceal their existing ailments.

  • Forged Documents
  • Health insurance buyer also sometimes submit fake documents to gain an advantage. It is a well-known fact that insurers tend to offer lower premiums to younger applicants. Hence, policy buyers may submit fake proof of age to conceal their actual age.

  • Duplicate Bills During Claim
  • A health insurance policy works by paying out medical expenses incurred by the policyholder due to illness or surgery. When the policyholder incurs no such expenses, they fabricate medical bills to gain a profit via the insurance claim. This is also a common insurance fraud in India. Sometimes, instead of submitting fake bills, policyholders may also submit inflated bills to gain profits.

  • Using Multiple Policies

It is legal to purchase multiple health insurance policies and use a combination of both to pay for your medical bills. However, policyholders sometimes claim the same expenses on both of their policies, thus getting a pay-out twice and making a profit. The correct way to use more than one policy is to inform your insurer about the existence of all your policies at the time of claim.

Conclusion

Health insurance fraud can occur to anyone if they’re not too careful. Not just insurers but policyholders themselves can be the victim of insurance fraud by intermediaries. Sometimes, intermediaries may be committing fraud against an insurer and using policy applicants without their knowledge. Therefore, one must be aware of such fraudulent acts and steer clear of such situations that can put them in tight spots.

Kotak e-Term Plan

Download Brochure

Features

  • Nominal Cost
  • Multiple Plan Options
  • Flexible Payout Options
  • Critical Illness Rider
  • Tax Savings
  • Long term Coverage

Ref. No. KLI/22-23/E-BB/492

T&C

- A Consumer Education Initiative series by Kotak Life

Similar Articles

Choosing Health Insurance for Senior Citizens

Health Insurance Plan for Cancer: What You Should Know on Symptoms and Diagnosis of Cancer

How is Health Insurance Cost Calculated?

Health Insurance Coverage: Day Care Treatment Vs OPD Treatment

5 Reasons to Buy Health Insurance in 2021

7 Reason Why Should You Buy a Health Insurance Plan in Your 20s?

Health Insurance with or Without Medical Tests? Which is Better

What Does Health Insurance Not Cover?

Why Should You Opt for Cancer Insurance?

How do I Choose a good Health Insurance Plan?

Is Health Insurance the Same as Medical Insurance?

Everything You Need to Know About Accidental Insurance Policy

Key Difference between Health Insurance and Mediclaim Policy

What is the Difference Between a Mediclaim Policy, Health Insurance and Term Insurance?

Why Opting for Short Term Health Insurance Plans is a Wise Idea?

Buying Health Insurance with A Pre-Existing Illness? Things You Should Know

How to File Health Insurance Claims?

Stress and Heart Health: 4 Things You Should Know

Key Factors that Decide Your Eligibility for Buying Health Insurance Plans

Is Cataract Surgery Covered under Health Insurance in India?

5 things to consider while renewing a health insurance policy

Rashtriya Swasthya Bima Yojana: Eligibility, Coverage, Benefits

Healthy Habits to Avoid Falling Sick During Monsoon

What Is the Restoration Benefit in Health Insurance Plan?

Tips to Reduce Your Health Insurance Premium

What is Telemedicine? How to Seek Medical Treatment Remotely?

What are the Documents Required for Buying a Health Insurance Plan?

What is Health Insurance and Why do You Need it?

Top Five Institutes for Free Cancer Treatments in India

Are You Covered for the Home Treatment Cost Under Your Health Insurance Policy?

What Is the Restoration Benefit in Health Insurance?

Saving Tax on Your Health Insurance

Is Health Insurance Non-taxable?

Benefits of Health Insurance You May Not Know About

Critical Illness Can Disrupt Family's Financial Goals and How Health Insurance Can be Useful

Health Insurance Plans for a Pre Existing Condition

Health Insurance for Brain Tumour: What You Should Know on Symptoms & Diagnosis of Brain Tumour

How Is Your Health Insurance Premium Affected By Age?

What is Single Premium in Health Insurance?

How to Claim Tax Benefits on Medical Insurance Premium?

List of Critical Illnesses Covered in Health and Life Insurance Plans

5 Reasons to Consider Investing in Health Care

Why is Cardiac Care Plan a boon for Heart Patients?

Tax Benefits on Health Insurance Plans

How to Choose a Right Health Insurance Plan?

Section 80D: Everything You Need to About Income Tax Deduction for Medical Expenditure

How to Transfer Your Health Insurance Cover Without Losing Benefits?

Health Insurance Plan for Family

Health Insurance for Students Who Study Abroad

What do Health Insurance Plans Cover?

Health Insurance for Personal Accidents

Difference Between Open Heart and Bypass Surgery

Things to keep in mind before buying a health insurance plan for diabetics

All You Need To Know About No-Claim Bonus In Health Insurance

10 Effects of Fast Food on Your Body

How Much Should I be Paying for Health Insurance?

What is OPD Cover in Health Insurance?

6 Common Myths about Health Insurance

Seven Preventive Measures for Heart Related Illness

10 Preventative Measures for Diabetes

Why You Must Disclose Your Pre-Existing Conditions When You Buy Health Insurance

Heart and Cancer Insurance

Why do Patients with Hypertension Need Health Insurance?

What Medical Expenses Can You Claim in Health Insurance Plans?

Types of Health Insurance You Must Know About

Why Your Health Insurance Cover Could be Insufficient?

5 Reasons to Own Both Health Insurance and Term Insurance

Which Health Insurance Plans Cover Your Family Members?

Health Insurance Coverage for HIV Patients

Basics of Health Insurance

What are Health Insurance Premiums? How are they Calculated?

Health Insurance Plan for Heart – What you Should Know on Symptoms and Diagnosis of Heart-Related Disease?

How to Buy ₹1 Crore Life Insurance Policy Without Medical Test?

What is International Health Insurance? Meaning, Importance and Benefits

The Importance of a Health Insurance Claim Ratio

Everything You Need to Know About the Ayushman Bharat Health Insurance Scheme

Factors to Consider While Choosing a Health Insurance Plan for Your Parents

Steps to Appeal A Health Insurance Claim Denial

Why You Must Review Your Health Insurance Policy/ Plan Every Year?

How Your Eating Habits Affect Your Health & How to Change Them

What is the Right Age to Buy Health Insurance Policy?

Which One is Better: Mediclaim or Health Insurance?

Why You Must Review Your Health Insurance Plan Every Year

Does Critical Illness Insurance Cover Stroke?

Do Add-On For Health Insurance Policies Really Add Value?

Protect Your Family with Health Insurance Today

What is Disability Insurance?

What is the Persistency Ratio and Why Does it Matter to the Health Insurance Sector?

How Much Health Insurance Cover Should You Opt For?

Health Insurance for Liver: What You Should Know About the Symptoms and Diagnosis of Liver Problems

Critical Illness Insurance for Alzheimer's Disease

How Much Of Health Insurance Is Tax Deductible?

A Millennial’s Guide to Buying Health Insurance

7 Things to Audit in Your Health Insurance Plan

Why You Need to Know About the Critical Illness Plan?

Why You Must Disclose Your Pre-Existing Conditions While Buying Health Insurance?

How to Switch to A Different Health Insurance Company?

How wellness benefits can help reduce your health insurance premium

How To Choose A Good Health Insurance Plan?