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Action against fraud

Workings of group 3 Insurance Institute of India, Feb 23-24

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 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


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

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

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


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

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

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 TPAs and Investigating agencies? Should we include other stakeholders?

Regional forums Vs National forums ?

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