Understand about Health Insurance frauds

Health insurance fraud is one of the major crimes which can pose serious implications both on the part of consumers and policymakers.  As the health insurance industry is expanding so frauds also increasing. To avoid facing such kind of implications, it is a must to be aware of various forms under which health insurance frauds take place.

Different form of Health insurance frauds:

Opportunity Fraud: Any information which is misleading or inaccurate is considered as opportunity fraud. This happens usually from policyholder’s part to ensure that the underwriting of insurance policy done in their favour.

Deliberate fraud: It is a kind of accident or loss that is covered under the policy is presented purposely to avail of the benefit.

External Fraud: It is a kind of fraud that is committed by the policyholders, vendors, beneficiaries, or against a company.

Internal Fraud: This fraud is committed against a company or a policyholder by the employees of the insurance company such as executives, managers, or agents.

Fraud committed by Policyholders: A customer now well smart to understand the features and terms and conditions of the insurance policies to avail of the benefits by practicing fraudulent activities. Some of the most common frauds are claim fraud, eligibility fraud, or application fraud.

Claim fraud: It is one of the most practiced fraud at present. It happens when a policyholder makes an illegal claim to get the benefit from the policy. It is considered as claim fraud. Some of the examples of claim fraud are un-witnessed accidents, invisible injury, insured, and physicians in together committing a fraud. Apart from this, some of the healthcare providers are also practicing claim frauds by billing insurers for the treatment, which is covered under their health insurance plan, even no treatment of such kind is done. Some policyholders buy various health insurance policies without giving any kind of information to the insurance providers to enjoy claim settlement from all of them.

Eligibility Fraud: The policyholders are committing this fraud by giving inaccurate or false details regarding eligibility. They give incorrect information about their employment status, family details, or any pre-existing diseases.

Application fraud: The policyholders are doing this fraud by providing wrong information in the application related to diseases they suffer from, claims, etc., to avail of the extra health benefits.


Since the health insurance companies are facing a lot of issues, it is a must to be aware of these kinds of fraud. Earlier, health insurance policies covered medical expenses incurred only in India, but now some policies offer coverage for treatments abroad as well. Companies have also started offering health insurance for AYUSH treatments or alternate medication now.