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Insurance fraud or false insurance claims are insurance claims filed with the intent to defraud an insurance provider.

In the United States insurance fraud is estimated to cost US$875 per person per year with The Coalition Against Insurance Fraud estimating the loss to be $80 billion per year and Medicare estimating fraud in its system costs the government $179 billion per year. According to Celent, the amount of fraud that is actually addressable ranges from 1% to 4% of claims or expenses in the different sectors of the insurance industry.

Insurance fraud hurts the average person in two ways. First, all fraud costs, including losses, investigations, etc., are paid for by the insured through higher premiums, or, in the case of government insurance like Medicare, in higher taxes. Second, if a particular individual is the target for the fraud, they have costs such as deductible payments, loss of property use, etc., as well as higher premiums from the claim loss and the potential for denial of future coverage.

Some memorable examples of insurance fraud include the following:

• Former British Government minister John Stonehouse went missing in 1974 from a beach in Miami. He was discovered living under an assumed name in Australia.
• Derek Nicholson and Jottie Nagle were accused of attempting to defraud a life insurance company for $1 million after Mr Nicholson apparently went missing in New Jersey in July 2003 and Ms Nagle reported him missing and made a claim on the policy.
• Gaylan Sweet of San Diego, California, who was a claims adjuster for Allstate Insurance set up a scheme in 2002 that included non-existent children who were killed in hit-and-run auto accidents at non-existent intersections by phantom drunk drivers. Sweet and two others (who posed as the parents of the non-existent children) pocketed $710,000 before being caught by Allstate.

Health insurance fraud

Health insurance fraud is described as an intentional act of deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or group.

Studies show that over 30 billion dollars is lost each year to health care fraud in the United States. In order to control costs, insurance companies have found it necessary to investigate fraud for the benefits of the members.

Fraud can be committed by both a member and a provider. Member fraud consists of ineligible members and/or dependents, alterations on enrollment forms, concealing pre-existing conditions, failure to report other coverage, prescription drug fraud, and failure to disclose claims that were a result of a work related injury. Provider fraud consists of claims submitted by bogus physicians, billing for services not rendered, billing for higher level of services, diagnosis or treatments that are outside the scope of practice, alterations on claims submissions, and providing services while under suspension or when license have been revoked. Independent medical examinations are used to de-bunk false insurance claims and allow the insurance company or claimant to seek a non-partial medical view for injury related cases.

In response to the increased amount of health care fraud in the United States, Congress, through the Health Insurance Portability & Accountability Act of 1996 (HIPAA), has specifically established health care fraud as a federal criminal offense with punishment of up to 10 years of prison in addition to significant financial penalties.

Footnotes

1. ^ Celent Report: According to figures published by Celent 19 March 2007. See also Insurance Fraud Mitigation Technology: Beyond Red Flags.

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