Health insurance claim fraud: the common types
Health insurance works because many honest people share the cost of a few large claims. Fraud pushes premiums up for everyone. Insurers and TPAs therefore look carefully at some claims. Understanding the common types helps genuine customers see why questions are asked, and helps claims teams know what to look for.
Common types of health claim fraud
1. Non-disclosure of a pre-existing condition. A known illness is left out of the proposal form, then claimed soon after the policy starts.
2. Inflated bills. Real treatment, but with charges padded, extra items added or bills altered.
3. Fake or "paper" hospitalisation. The patient was not actually admitted, or the stay was for a day-care procedure presented as a longer admission.
4. Unnecessary treatment. Admission or procedures that were not medically needed, sometimes arranged with a hospital.
5. Identity misuse. Another person is treated under the insured person's name.
6. Duplicate or multiple claims. The same bills submitted to more than one insurer.
7. Forged or altered documents. Discharge summaries, test reports or receipts that have been edited.
Red flags investigators look for
- Claims soon after the policy begins
- Admission or discharge timings that do not match the story
- A hospital that cannot be located or is not as described
- Statements from the patient, family and hospital that do not agree
- Bills that do not match the treatment
How investigations work
An investigator checks the patient's identity, the hospital, the treatment history and the documents, and asks the patient or family for their account. In a fair process, the claimant gets a chance to explain anything that looks unusual.
How Praman helps
Praman by SatyaSakshi lets insurers and TPAs take a recorded video statement from the patient or family on a WhatsApp link, with location, time, photos of documents and a face match. Questions are tailored to health claims, and the AI flags inconsistencies for the investigator. Hospital audits can be done on a live video tour. The investigator reviews all the evidence and approves the final result, so genuine claims move faster.
Frequently asked questions
Are most health claims fraudulent?
No. The large majority are genuine. Investigations exist to find the small share that are not, and to keep premiums fair for everyone.
What should a genuine claimant do?
Keep records: discharge summary, bills, reports, prescriptions and payment proofs. Answer questions honestly. Genuine claims are paid.
How long does an investigation take?
It depends on the case. Video statements and instant checks can shorten the time compared with waiting for a field visit.
Related: how Praman handles this for businesses · all instant checks
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