Ease Healthcare Solutions

Health claim verifications (Intimations, Cashless & Reimbursement)

Ease Healthcare Solutions is providing the service of Health Claims Investigation to insurance companies. The Health insurance industry is growing and being chanted about like the new mantra, but still India is facing a huge loss in this sector because of the everyday increasing fraud claims. Some scams involve double-billing by doctors who charge insurers for treatments that never occurred, and surgeons who perform unnecessary surgery. We are able to find out all loopholes in the area of Fraudulent Health Claims include:

• Investigation of chronicity of the disease
• Investigation of surgeries included
• Investigation of billing (hospital/doctors)
• Investigation of the prescriptions (drugs/injections)
• Investigation of final reports of all health check-ups

We have a dedicated team of investigators who are well versed with the kinds of frauds under Health Claims. We verify each and every aspect of the claim with their vigil eyes and ascertain the authenticity of the claims.

We continuously strive to help you to provide a consistently high standard of service and understand the extensive enquiries related to the Insurance sector. We discuss all the issues in complete confidential manner which is also included non-disclosure agreement where necessary.

Personal Accident (PA) Claim verifications (Death/PPD/TPD)

The accident victim is perhaps the most important source of information about the circumstances of an accident. Following an accident, and after ensuring that all individuals involved in the accident are safe and receive the necessary medical care, including the rider and passenger, the investigator should collect as much information as possible. The information can prove invaluable in assisting an accident investigation and our reconstruction team in recreating the most accurate account of the accident. Notes, photos, sketches, and witness accounts can all be crucial elements in the investigation and reconstruction, and can provide the most solid factual foundations upon which accident claims can be proven.

We use many investigation tactics to help insurance companies reduce their exposure to deceitful acts of the claimants and we cover the following information about each incident:

• Full name, address and occupation of the injured person
• Date and time of the accident
• Place where the accident happened
• Cause and nature of the injury
• Name, address and occupation of the person notifying you, if this is not the injured person

It is often difficult to obtain sufficient credible evidence in suspicious claims. Our ultimate goal is to help claim handlers to adhere a comprehensive investigative plan that is appropriate for every claim, balancing the risk of fraud and the practical cost of investigation.

We continuously strive to help you to provide a consistently high standard of service and understand the extensive enquiries related to the Insurance sector. We discuss all the issues in complete confidential manner which is also included non-disclosure agreement where necessary.

Critical Illness (CI) claim verifications

It is a type of health insurance under the category of fixed benefit plans. It offers a fixed amount to the insured in case of the diagnosis of a critical illness mentioned in the policy like cancer, stroke, heart attack, paralysis. The plan provides financial help for the treatment of these diseases. Thus, the insurance helps manage health care expenses without making a hole in the pocket or affecting other financial responsibilities.

Fraudulent Critical illness claims are including, hiding the past medical or surgical history of insured and past hospitalization details, policy eligibility criteria and employment details etc. In this scenario we used to get below details and documents to detection of fraud critical illness claim include:

• Any disease caused either due to prolonged usage of tobacco, drugs or alcohol
• Any pre-Existing conditions / its complications with duration
• Any diseases caused by disability from birth
• Any health conditions caused by giving birth - includes C-section
• Sexually transmitted diseases like HIV AIDS
• Defence operations like fighting in a war, military duties, or terrorist attack
• Any surgeries or dental treatments
• Treatment took due to infertility, or any hormonal replacements, and any surgery for reproductive purposes
• If death occurs within the first month of being diagnosed with a disease

Ease Healthcare Solutions conducts extensive fraudulent Critical illness claim investigations and is accustomed to providing investigative assistance to special investigative units or counsel. We continuously strive to help you to provide a consistently high standard of service and understand the extensive enquiries related to the Insurance sector. We discuss all the issues in complete confidential manner which is also included non-disclosure agreement where necessary.

Life Insurance claim verifications (Pre policy, Post policy & Death)

Life insurance is a safeguard for family members if the major suppliers of income were to die and it was to grievously upset the common means for providing the basics of life. This does not include the burdens of financial expenses for burial, taxes, unplanned or emergency expenses, and furthered educational expenses for children or to have the spouse go back to school to become the primary breadwinner of the family. Insurance fraud is one important manifestation of a decline in moral standards that is fundamentally destructive of society.

According to our guidelines and rules, it is a crime if you knowingly, and with intent to injure, defraud or deceive insurance companies, or provide any information, including filing a claim, which contains any false, incomplete or misleading information. These actions, as well as submission of materially false information, can be resulted in denial of the claim, and are subject to prosecution and punishment to the full extent under state and/or federal law through our investigation services.

In the context of detection of fraud our life claim investigation services include:

• Background Histories
• Contestable Investigations
• Disappearance
• Evidence Documentation
• Fraudulent Claims Investigations
• Homicide
• Interviews/Statements
• Medical Records
• Public Records
• Surveillance / Activity Checks

Ease Healthcare Solutions conducts extensive fraudulent Life insurance claim investigations and is accustomed to providing investigative assistance to special investigative units or counsel. We continuously strive to help you to provide a consistently high standard of service and understand the extensive enquiries related to the Insurance sector. We discuss all the issues in complete confidential manner which is also included non-disclosure agreement where necessary.

Workmen’s Compensation (WC) claim verifications

Fraudulent workers’ compensation claims can be hazardous to the financial wellbeing of your business. To determine the legitimacy of a claim, an examiner will conduct a workers’ compensation claim investigation.

The investigation seeks to determine two things:

• Is the employee as injured as they claim to be?
• Was the injury acquired while the person was working?

For example, an employee who is injured outside of work Tuesday night but comes in the next day and files a claim indicating that the injury happened at work would be filing a fraudulent workers’ comp claim. Ideally, an investigation would uncover that lie.

Fraudulent personal injury claims can be equally as hazardous as fraudulent workers’ compensation claims.

Personal injury claims can be filed against either a business or against another person. The claim becomes fraudulent when the victim actually fell on their own icy steps but staged the incident to look like it occurred in front of a company’s storefront.

Ease Healthcare Solutions conducts extensive fraudulent WC claim investigations and is accustomed to providing investigative assistance to special investigative units or counsel. We continuously strive to help you to provide a consistently high standard of service and understand the extensive enquiries related to the Insurance sector. We discuss all the issues in complete confidential manner which is also included non-disclosure agreement where necessary.

Cattle claim verifications

Cattle are considered one of the most valued possessions of the rural community. Marginal, small and medium farmers earn considerable portion of their income from cattle rearing. Since the livelihood of farmers depend so much on them, it becomes important to get cattle insurance for comprehensive coverage against cattle loss. Cattle insurance is another endeavor of the Government of India to protect the agro-based economy of the country.

There are two types of risks which are insured under this policy.

• Death of cattle: It covers loss of life due to accident or injury and disease occurred due to surgical infection
• Permanent Disability cover: It covers the risk of permanent and complete disability

Besides death or disability caused by fire, road accidents, drowning, electrocution, snake bites or poisoning, cattle insurance offers coverage for other issues as well. They include:

• Death due to natural calamities like storms and earthquakes
• Death due to disease, infection or calving during surgical operations
• Permanent disability, for milch cows this refers to incapacity to conceive and yield milk. For bulls, this refers to incapacity to breed.

In India, cattle insurance claimants are required to cut off part of the deceased animal’s ear with the punched ear tag and submit it to the insurance company. This leads to concerns regarding the relatively primitive system’s vulnerability to fraud.

The cattle insurance scheme is a loss-making one. Since at least 90% of the claims, we received were false.

The ear is taken from the slaughterhouse and punched with a tag. The insurer is then informed over the weekend about the animals’ death, and by the time an inspector arrives at the scene, the carcass is already decomposed, leaving only an ear and a medical report. In many cases, even the veterinarians and bank officials are in on the scheme.

Though our investigation seeks to determine the below verification details include exact circumstances of the cattle claim

• Theft or clandestine sale of cattle
• Neglect, over-loading and treatment under unskilled doctors
• Using for other purpose than what has been mentioned in the claim proposal
• Not treating when sick or not taking any initiative to prevent the death
• Accidents or injury which occurred before the commencement of the policy
• Slaughtering without permission from the veterinary or government official

Opinion: The system uses radio frequency readable ear tags, which are easier to read in any situation and are backed up by comprehensive datasets relayed by satellite, which can be queried for a number of aspects”. This will be vital in reducing livestock insurance fraud.

It is often difficult to obtain sufficient credible evidence in suspicious claims. Our ultimate goal is to help claim handlers to adhere a comprehensive investigative plan that is appropriate for every claim, balancing the risk of fraud and the practical cost of investigation.

We continuously strive to help you to provide a consistently high standard of service and understand the extensive enquiries related to the Insurance sector. We discuss all the issues in complete confidential manner which is also included non-disclosure agreement where necessary.