Dr. Rajendra S. BangalMBBS, MD (Forensic Medicine), DNB (Legal Medicine), LL.B.

EXPERT MEDICOLEGAL CONSULTANCY PVT. LTD.

ROAD BLOCKS IN VERIFICATION: At Hospitals

Non-cooperation by hospital owner in individual owned hospitals

No access in corporate hospitals Delay in providing documents The charges are not fixed and depend from

patient to patient.

Hospital pharmacy does not share the computerized data and stock register.

Hospitalizations on weekends (in case of cashless cases)

Unaccounted expenses Non-cooperation of certain agencies like

school/ colleges, Employer – hence the delay.

Rude behavior by hospital owners/ consultants

Cannot control kick backs, excessive and unnecessary investigations

ROAD BLOCKS IN VERIFICATION: With insured

Refuse to give statements in writing It is not possible to meet the unreasonable

expectations of ICs which are also bad in law.

Neighbors do not provide statements.

ROAD BLOCKS IN VERIFICATION: With Physicians

Some doctors charge for giving statements. They refuse to come face to face. Non-availability of doctors Rude behavior

ROAD BLOCKS IN VERIFICATION: With ICs

Authorization of patients not sent to verification agencies.

Policy T &C, Type of policy, details given by the patient in the proposal form is not made available.

Impracticable TATs.

ROAD BLOCKS IN VERIFICATION: Solutions

ICs should take cognizance of the grievances of verification agencies.

They should have a mechanism to take strict action against the defaulters.

The investigators should be given an authority and instructions to hospitals to honour their authority.

Pan India Presence

Criteria for selection of vendors. Feasibility of PAN India agencies. Assurance of volume. Effectiveness of regional and zonal

agencies vis a vis so called Pan India agencies

Ways to carry out investigations

INVESTIGATION ACTIVITIES

PRE INVESTIGATION FIELD INVESTIGATION POST INVESTIGATION

PRE INVESTIGATIONS

Peruse records thoroughly Immediately note down the discrepancies Prepare general plan of action for

investigations No place should be required to be visited

twice- unless for follow up

PRE INVESTIGATIONS (Contd…) Note down all contact numbers with names

required for reference during field investigation

Note plan of action and visitation on single sheet

Plan of investigations All points should be covered Scope of investigations

PRE INVESTIGATIONS

Peruse claim documents and note details

Duration between policy and claim Address Age Spacing of policies Occupation/ license Medical documentation Habits Hobbies etc.

FIELD INVESTIGATION

Before commencing, peruse the plan of action and plan of visitation

Make a visit to the place of occurrence Take photographs Do not take short cuts while investigating

FIELD INVESTIGATION (contd …)

Never ignore any additional information as unwanted

Get available verifiable documents and additional information verified for its authenticity.

In case of a lady name, get her maiden name. Take all facts, statements in writing

FIELD INVESTIGATION (contd …)

Never leave work for next day. Do not assume / deduce a fact or document to

be true/ false on your own. Get it verified. Do not automatically discredit information that

is unfavorable to your position. Do not assume non cooperation (Non-

cooperation comes only where vested interests are involved.)

FIELD INVESTIGATION

Meet other doctors and chemists in neighboring areas of the treating doctor/ hospital.

Meet chemists near hospital, also pathology labs in the vicinity

If record not available with chemist near hospital, go to chemist near his residence

Also enquire with relatives, friends, colleagues, neighbors etc

Ask the nurse, peruse nursing notes What was the cause? Do you have any knowledge

about his cause of death ?

POST INVESTIGATION

Logical conclusion of investigation Report to be in sequence of events In simple language Record multiple visits if done Place all relevant evidence on record-

including contact numbers.

POST INVESTIGATION (contd…) Filing to be neat and proper Send hard as well as soft copies Index all contents in the report If information to be obtained at a later date-

mention so.

POST INVESTIGATION

Mention locality of the claimant’s residence. Hospital- residence distance Chemist- residence distance Medical history details Age proof Occupation Income and Source of income Habits/ hobbies

POINTS TO BE KEPT IN MIND

Do your homework. Documentation should be in detail Always make check list for reference Be polite but firm Do not apply short cuts Be thorough Keep all necessary items required for

investigations (tape, carbon paper, camera, pen etc.)

POINTS TO BE KEPT IN MIND

Bring evidence in support Do not ignore additional information First go to the opposite side where the insured

lives Ask open ended questions Ask close ended questions only when we need

to confirm facts Remember to collect facts

Claimant’s Interview

Meet only if necessary Meet him in the end Be very polite but firm Ask only relevant questions Check for delay in date of death and

intimation to the insurer. Look for its reasons Try to get more than 2 age proofs.

Age Proof

PAN Card/ Ration Card should not be collected as proof for age.

Instead voter’s list (preferably state list) can help.

How much should be the age difference for it to be significant: If age is >60 years: Then upto 7 years If age is <60 years: Then not more than 10 years

Never commit claim decision to the claimant to obtain documents

Take photographs of Life Assured and nominee

Take notice of living standard of nominee Interview lady member in presence of some

adult family member and record his/ her name. Discretely interview children Get details of his/ her mediclaim policies.

REMEMBER

Be thorough, polite, firm and alert Collect all relevant documents Do not leave any point unattended Check the records and take the verification in

writing No need to obtain documents if already

submitted to the company.

Details of family and dependents with age Statement of spouse, colleagues, relatives,

doctor etc. (preferably in their own handwriting)

Any other relevant details

TELE-CALLING Hospitalization verification Investigations before authorization Investigations for PED in planned surgeries. Investigations after claims are lodged. Audit based investigations – getting triggers

from audits (TPA oriented audits, hospital oriented audits)

PATIENT VERIFICATION AT THE TIME OF CASHLESS APPROVAL

Effectiveness of cashless verification.

Sr.No Category

Total No of claim Verified

Total Presumptive Saving

Average presumptive saving per Claim

1PATIENT WAS NOT

ADMITTED 560 20,575,546 36,742

2 Exorbitant 3233 43,357,227 13,411

3 Not co-operative 138 889,515 6,446

4 Room Rent 420 4,820,055 11,476

5 Pre-existing Aliments 272 2,247,468 8,263

6Pregnancy related

Expenses 63 189,000 3,000

4686 72,078,812 15,382

HOSPITALIZATION VERIFICATION STATISTICS DURING PERIOD 1-1-2011 TO 31-12-2011.

ROI

REPRESENTATIVE FIGURES OF A GROUP POLICY

TOTAL CASES

INVESTIGATED

FRAUDS DETECTE

D

CLAIM VALUE

PRESUMPTIVE SAVING PER

CLAIM

INVESTMENT PER CLAIM

368 110 3227058 29337 1500

ROI = 19.55 TIMES

USE OF TECHNOLOGY

Permissions required. CCTV permissions required for CCTV, Ham

radio, walkie talkie- Ministry of telecommunication.

Sec 415 IPC

Whoever, by deceiving any person, fraudulently or dishonestly induces the person so deceived to deliver any property to any person, or to consent that any person shall retain any property, or intentionally induces the person so deceived to do or omit to do anything which he would not do omit if he were not so deceived, and which act or omission causes or is likely to cause damage or harm to that person in body, mind, reputation or property, is said to "cheat".

Explanation

A dishonest concealment of facts is deception within the meaning of this section.

Sec 463 IPC- Forgery

Whoever makes any false documents or false electronic record or part of a document or electronic record, with intent to cause damage or injury, to the public or to any person, or to support any claim or title, or to cause any person to part with property, or to enter into any express or implied contract, or with intent to commit fraud or that fraud may be committed, commits forgery.

Sec 464 IPC- Making a false document

A person is said to make a false document or false electronic record who dishonestly or fraudulently  (a) makes, signs, seals or executes a document or part of a document;  (b) makes or transmits any electronic record or part of any electronic record;  (c) affixes any digital signature on any electronic record;  (d) makes any mark denoting the execution of a document or the authenticity of the digital signature, 

with the intention of causing it to be believed that such document or part of document, electronic record or digital signature was made, signed, sealed, executed, transmitted or affixed by or by the authority of a person by whom or by whose authority he knows that it was not made, signed, sealed, executed or affixed.

Sec 468 IPC- Forgery for purpose of cheating

Whoever commits forgery, intending that the document or Electronic Record forged shall be used for the purpose of cheating, shall be punished with imprisonment of either description for a term which may extend to seven years, and shall also be liable to fine.

Sec 471 IPC: Using as genuine a forged document or electronic record

Whoever fraudulently or dishonestly uses as genuine any document or electronic record which he knows or has reason to believe to be a forged document or electronic record, shall be punished in the same manner as if he had forged such document or electronic record.

Sec 191 IPC: Giving false evidence Whoever, being legally bound by an oath or

by an express provision of law to state the truth, or being bound by law to make a declaration upon any subject, makes any statement which is false, and which he either knows or believes to be false or does not believe to be true, is said to give false evidence.

 

Explanation 1  A statement is within the meaning of this section,

whether it is made verbally or otherwise.

Explanation 2  A false statement as to the belief of the person attesting is

within the meaning of this section, and a person may be guilty of giving false evidence by stating that he believes a thing which he does not believe, as well as by stating that he knows a thing which he does not know.

Sec 197 IPC: Issuing or signing false certificate

Whoever issues or signs any certificate required by law to be given or signed, or relating to any fact of which such certificate is by law admissible in evidence, knowing or believing that such certificate is false in any material point, shall be punished in the same manner as if he gave false evidence.

Sec 198 IPC: Using as true a certificate known to be false

Whoever corruptly uses or attempts to use any such certificate as a true certificate, knowing the same to be false in any material point, shall be punished in the same manner as if he gave false evidence.

 

Sec 199 IPC: False statement made in declaration which is by law receivable as evidence

Whoever, in any declaration made or subscribed by him, which declaration any Court of Justice, or any public servant or other person, is bound or authorized by law to receive as evidence of any fact, makes any statement which is false, and which he either knows or believes to be false or does not believe to be true, touching any point material to the object for which the declaration is made or used, shall be punished in the same manner as if he gave false evidence.

Sec 201 IPC: Causing disappearance of evidence of offence, or giving false information to screen offender Whoever, knowing or having reason to believe that an

offence has been committed, causes any evidence of the commission of that offence to disappear, with the intention of screening the offender from legal punishment, or with that intention gives any information respecting the offence which he knows or believes to be false: If capital offence : 7 years Punishable with life imprisonment : 3 years punishable with less than ten years’ imprisonment : 1/4th part of

the imprisonment

Sec 205 IPC: False personation for purpose of act or proceeding in suit or prosecution

Whoever falsely personates another, and in such assumed character makes any admission or statement, or confesses judgment, or causes any process to be issued or becomes bail or security, or does any other act in any suit or criminal prosecution, shall be punished with imprisonment of either description for a term which may extend to three years or with fine, or with both

Sec 17 Contracts act: Fraud "Fraud" means and includes any of the following acts

committed by a party to a contract, or with his connivance, or by his agents, with intent to deceive another party thereto his agent, or to induce him to enter into the contract; (1) the suggestion as a fact, of that which is not true, by one who

does not believe it to be true; (2) the active concealment of a fact by one having knowledge or

belief of the fact; (3) a promise made without any intention of performing it; (4) any other act fitted to deceive; (5) any such act or omission as the law specially declares to be

fraudulent.

 

Explanation.—Mere silence as to facts likely to affect the willingness of a person to enter into a contract is not fraud, unless the circumstances of the case are such that, regard being had to them, it is the duty of the person keeping silence to speak, or unless his silence, is, in itself, equivalent to speech.

TRAINING MODULE FOR INVESTIGATION- An Insight

Claim Investigation: Enquiry into unfamiliar and questionable issues

ATRIBUTES OF AN INVESTIGATOR Inquisitive Observant Focused Openminded Curious Perseverant Persistent Good Mannered

ATRIBUTES OF AN INVESTIGATOR Good Listening Skills Unbiased mind Unprejudiced mind Ability to play role Ability to put people at ease Ability to obtain other’s cooperation Ability to reach a logical conclusion

INVESTIGATION IS NOT ONLY ABOUT

Collecting Documents Verifying Facts

INVESTIGATION IS ABOUT

Thorough enquiry into the matter Systematic planning of investigation Triggering an investigation

Identify red flags Create Hypothesis (what could have happened) Scrutinize the investigating agency Should walk away with positive evidence Collate the data obtained.

REMEMBER

Try to inculcate talent to identify fraud at all levels (continuous nurturing is necessary)

There is no secret recipe for cracking a fraud To find facts that are not mentioned while

taking the policy

Identify the facts and details which do not allow people to cheat the insurance company

Try to prove al manipulated cases as negative (and not to prove genuine cases as negative)

To gather evidence to back our conclusion.

INVESTIGATION ACTIVITIES

PRE INVESTIGATION FIELD INVESTIGATION POST INVESTIGATION

PRE INVESTIGATIONS

Peruse records thoroughly Immediately note down the discrepancies Prepare general plan of action for

investigations No place should be required to be visited

twice- unless for follow up

PRE INVESTIGATIONS (Contd…) Note down all contact numbers with names

required for reference during field investigation

Note plan of action and visitation on single sheet

Plan of investigations All points should be covered Scope of investigations

PRE INVESTIGATIONS

Peruse claim documents and note details

Duration between policy and claim Address Age Spacing of policies Occupation/ license Medical documentation Habits Hobbies etc.

FIELD INVESTIGATION

Before commencing, peruse the plan of action and plan of visitation

Make a visit to the place of occurrence Take photographs Do not take short cuts while investigating

FIELD INVESTIGATION (contd …)

Never ignore any additional information as unwanted

Get available verifiable documents and additional information verified for its authenticity.

In case of a lady name, get her maiden name. Take all facts, statements in writing

FIELD INVESTIGATION (contd …)

Never leave work for next day. Do not assume / deduce a fact or document to

be true/ false on your own. Get it verified. Do not automatically discredit information that

is unfavorable to your position. Do not assume non cooperation (Non-

cooperation comes only where vested interests are involved.)

FIELD INVESTIGATION

Meet other doctors and chemists in neighboring areas of the treating doctor/ hospital.

Meet chemists near hospital, also pathology labs in the vicinity

If record not available with chemist near hospital, go to chemist near his residence

Also enquire with relatives, friends, colleagues, neighbors etc

Ask the nurse, peruse nursing notes What was the cause? Do you have any knowledge

about his cause of death ?

POST INVESTIGATION

Logical conclusion of investigation Report to be in sequence of events In simple language Record multiple visits if done Place all relevant evidence on record-

including contact numbers.

POST INVESTIGATION (contd…) Filing to be neat and proper Send hard as well as soft copies Index all contents in the report If information to be obtained at a later date-

mention so.

POST INVESTIGATION

Mention locality of the claimant’s residence. Hospital- residence distance Chemist- residence distance Medical history details Age proof Occupation Income and Source of income Habits/ hobbies

POINTS TO BE KEPT IN MIND

Do your homework. Documentation should be in detail Always make check list for reference Be polite but firm Do not apply short cuts Be thorough Keep all necessary items required for

investigations (tape, carbon paper, camera, pen etc.)

POINTS TO BE KEPT IN MIND

Bring evidence in support Do not ignore additional information First go to the opposite side where the insured

lives Ask open ended questions Ask close ended questions only when we need

to confirm facts Remember to collect facts

Claimant’s Interview

Meet only if necessary Meet him in the end Be very polite but firm Ask only relevant questions Check for delay in date of death and

intimation to the insurer. Look for its reasons Try to get more than 2 age proofs.

Age Proof

PAN Card/ Ration Card should not be collected as proof for age.

Instead voter’s list (preferably state list) can help.

How much should be the age difference for it to be significant: If age is >60 years: Then upto 7 years If age is <60 years: Then not more than 10 years

Never commit claim decision to the claimant to obtain documents

Take photographs of Life Assured and nominee

Take notice of living standard of nominee Interview lady member in presence of some

adult family member and record his/ her name. Discretely interview children Get details of his/ her mediclaim policies.

REMEMBER

Be thorough, polite, firm and alert Collect all relevant documents Do not leave any point unattended Check the records and take the verification in

writing No need to obtain documents if already

submitted to the company.

Details of family and dependents with age Statement of spouse, colleagues, relatives,

doctor etc. (preferably in their own handwriting)

Any other relevant details

TYPES OF DEATH

NATURAL UNNATURAL

Suicides Homicides Accidents

In Homicides

FIR PM Report CA Report Copy of charge-sheet Statements Court Evidence Confirm possibility of claimant’s involvement

in murder

In Suicides

FIR PM Report CA Report News Paper Cutting

Death due to Burns

Dying declaration Statement given to attending doctor Time since death Postmortem report

Traffic Accidents

Spot Panchanama Who was driving the vehicle

Alcoholic Deaths

Acute Chronic Photograph of deceased, show it to wine shop/

bar. Ask frequency and quantity of purchase Enquire with de-addiction center Psychiatric hospitals

Drowning

Visit place of occurrence Enquire with surrounding shops/ houses/

hawkers etc

VARIOUS PROFORMAS

Provided separately