The number of people making fraudulent insurance claims is on the rise. However the major problem with this is that it pushes up the cost of insurance for everyone else.
"The medical profession is traditionally held in high regard but it too contains its sinners. A very exact picture has emerged from fraud-busters in South Africa, indicating that six per cent of bills submitted by doctors or hospitals for payment by insurance companies are wholly unjustified.
The figure was produced by Patrick Lubbe, financial director of Medical Services Organisation in Johannesburg. The risk-management company handles claims from 1.1 million people holding medical cover with 28 insurers and mutual benefit companies.
Mr Lubbe's staff of 180 – mainly former nurses – handle 60,000 medical and dental claims a month. From such a large database he is easily able to spot unreasonable claims from more than 6,000 "procedure codes" ranging from scans and blood tests to cyst removal and open-heart surgery.
"You'll be amazed how many dental providers try to pull out the same tooth six times," he says. "We think five to six per cent of admissions are not justified."
One doctor claimed 21 times for inserting grommets to overcome "glue ear" when the operation he had actually carried out was a cosmetic procedure – flattening "stick-out" ears. "He owed us 21 times 35,000 rand, (£2,600)," Mr Lubbe remarks dryly.
In another case, an orthopaedic surgeon attempted to charge three times the accepted rate for a knee operation. Some of the worst abuses involved emergency admissions, some brought in by helicopter. "When a patient lands, [some claimants] see a cheque book in dollars or pounds sterling."
Lifeinsure UK
