LOGO HEALTH INSURANCE FRAUD

Contents What is the health insurance fraud? 1 2 Who easy to get insurance fraud? 3 Conclusion 4 Which kind of health insurance fraud?

WHAT IS HEALTH INSURANCE FRAUD?  Health insurance fraud means that the customers intend to get incorrect benefits more than sum assured that customers should have gotten.  We concentrate in:  Cathay Accident Medical Rider (R03)  Cathay Child Accidental Rider (R02)  Cathay Medical Rider (R04)

THE COST  The cost of Fraud is impossible to quantify  Based on AIMA (The Academy of Insurance Medicine of Asia) conference, the large sum was loosen by health insurance fraud:  In USA, they estimate form 68$ to 175$ billion  In Saudi Arabia: 320$ million

THE COST & LOSS  As report in AVI (association of Vietnamese insurers) meeting in 2009, every year one big insurer company had to paid billions VN dong for Hospital rider.  The claims for hospital benefit in the North are higher than others many times.  The claims for hospital benefit at Ha Noi & HCM are always low.  Top 4 common diseases occupied 1/3 total claim cases: joint pain, bronchitis, virus infection & eye diseases.

WHAT KIND OF THE FRAUD?  Dishonestly makes a false representation  Hospitalize several times in a short period with nonsensical reason.  Submit false documents.  Stay at the hospital too long more than necessary to treat one simple disease.

WHO EASY TO GET INSURANCE FRAUD 10% of people- inherently honest 10% - inherently dishonest 80% of people could be influenced either way

WHO EASY TO GET INSURANCE FRAUD  Unemployed, retired  Housewife, househusband  Children  Teachers  Medical staffs  Workers  Agents

EXAMPLE  Hospital abuse: At Điện Biên province (in the North), one company bought hospital rider for 18 staffs with highest sum assured. Every staff had claims with common diseases: back pain, joint pain, red eye, vertigo, average 3 times/year. The investigator found that agent is vice president’s wife and relative of staff of a hospital. Timekeeping record showed that they were present at the office within the hospitalization period.

EXAMPLE  False document: One hospital at Quang Nam province, in 2007 & 2008 there are increase number of hospital claims with complete documents as medical report, discharge note, invoice…. The investigator found that life assured didn’t know anything about their hospitalization. Agents cooperated with high rank of medical staffs & FA at local hospital.

CONCLUSION  Have a closely term & condition  Train professional ethics to agents  Underwrite with clear-headed  Handle claim wisely, note & follow up any sign of insurance fraud, cooperate with UW to review or adjust regulation.

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