Modalities for Manipulating Insurance Claims from Fake Hospital Bills to Engineering Deaths

 

Insurance companies worldwide, including those in Indonesia, are gravely concerned about the plague of claims manipulation and false claims.

Claim manipulation is a claim that, according to the provisions of the policy, insurance companies should not have paid, according to Indonesian Operations Technical Director Re Delil Khairat.

The insurance company must still pay for these claims, nonetheless, because of manipulation and fraud against claims.

"The issue of false claims needs to be watched. The insurance sector in Indonesia is beset by a number of other issues, and under Covid-19 it appears that the emphasis on combating fraud is waning. Therefore, we are bringing this matter up again," he said on Monday, May 29, 2023.

According to the data gathered by Bisnis, BPJS Health to private insurance providers like Allianz Life have all documented incidences of claim manipulation.

The techniques differ as well, for instance, fabricating hospital bills or even orchestrating a death so that insurance claims are paid by the business. What's on the list?

Allianz Life Insurance Indonesia

There was a claim manipulation case against PT Asuransi Allianz Life Indonesia in 2018. On October 17, 2017, Allianz Life reported four individuals through their attorneys who were claimed to have purposefully used false identities when submitting life insurance applications and making claims.

The police report is recorded at Polda Metro Jaya with the number LP/5034/X/2017/PMJ/Ditreskrimum. The company suffered material losses totaling more over IDR 100 million.

The organization believes the 4 people who have been reported utilized bogus healthcare invoices in addition to utilizing false identities.

Once there is suspicion, the insurance provider checks the appropriate hospital, and this is then known. It appears that the hospital never issued the invoice.

The four individuals are claiming health insurance through a hospital cash plan program. Since 2015, the four of them have been Allianz clients.

BNI Life

By fabricating documents in 2020, PT BNI Life Insurance exposed the method of digital insurance death claim fraud. These results demonstrate the necessity for insurance providers to foresee fraud or criminality.

The management of BNI Life said that the business was successful in uncovering false claims made by its clients. The offender bearing those initials Digimicro BNI Life is a digital insurance policy held by HM.

HM filed a claim on his behalf, adding a death claim form as part of his deception strategy. According to the policy's benefits, HM's heirs are covered up to IDR 90 million.

Given that HM was still alive, management also informed the Binjai Police in North Sumatra about the crimes HM had committed. According to the reporting, claim documents were fabricated in order to receive unfair insurance benefits.

Indonesian law is broken by HM who declares themselves deceased and/or utilizes a document to support their claims. The case against the insurance criminal network was also reported by BNI Life, which was very alarming.

Mega Life, Astra Life, Allianz, and FWD

The life insurance sector identified a customer named Wahyu Suhada (35), who faked his own death in early June 2022 in order to get claim benefits totaling about IDR 15 billion.

Once upon a time, Wahyu, who was dissatisfied with his ability to profit from investments, thought it would be a good idea to fake his death in order to collect the claim values from his four life insurance policies.

Wahyu also took action on Saturday, April 6, 2022, at the Central Cikarang, Bekasi Regency, after enlisting the aid of friends. Wahyu and a coworker were riding a sizable motorcycle when they collided with the promised car, causing it to plunge into the Kalimalang River.

Wahyu had drowned in the river's flood, a fellow rider muttered as he begged for assistance from the onlookers. In actuality, Wahyu and his coworkers escaped in a car.

Fortunately, the Central Cikarang police who were informed of the report smelled something fishy during a volunteer search for Wahyu on the Kalimalang River. Wahyu, who is still alive and on the run, is now a suspect in the false reporting offense.

Astra Life

Astra Life, a life insurance company, has seen instances of fraud or acts of fraud conducted by agents.

Management stated that Otto Hasibuan's counsel had notified Astra Life to report this case to the Indonesian National Police on January 18, 2023.

24 Astra Life clients in East Java brought this matter to light by complaining that they never received their policies and requesting a refund of all insurance payments paid to Astra Life.

From there, there are claims that dishonest agents have perpetrated fraud. The explanation for this is that Astra Life said that all of these policies had been given to the concerned customer following a thorough investigation and verification of agent documents.

Astra Life's attorney Otto Hasibuan had previously urged any customers who had issues with the policy to write to Astra Life and their lawyer right away to get an explanation.

BPJS Kesehatan

According to Ali Ghufron Mukti, the main director of BPJS Kesehatan, fraud is still a problem in the health care industry in Indonesia.

According to him, the hospital engaged in fraud in connection with payment claims of billions of rupiah. According to Ali, hospital bills totaling billions of rupiah were submitted, but there were no actual patients to support them.

Ali Ghufron did not, however, name the hospitals that were involved in the crime. Ali claims that this occurrence was identified as a result of the use of the most recent system created by BPJS Kesehatan to keep an eye out for potential fraud in the midst of an improvement in the financial condition.

The scam that was relayed was one of the categories that the government had defined, according to BPJS Watch member Timboel Siregar.

Since the National Health Insurance Program (JKN) has been in operation, fraud has happened and continues to happen. Repeated readmissions or admissions are a type of fraud that happens rather frequently and is frequently experienced by JKN patients.

When JKN participants are not healthy enough to go home, they are instructed to do so. A few days later, JKN patients are instructed to return to the hospital.

"A common fraud that hurts JKN participants is the advice to purchase their own medication, despite the fact that this medication is covered by the JKN guarantee. Participants in the JKN are expected to split expenses by purchasing their own medication, he added.