Abu Dhabi residents told to report insurance fraud

Abu Dhabi: Insurance experts have urged residents in the emirate of Abu Dhabi to report any suspicion of manipulation on their health insurance policies. These include the scheduling of unnecessary surgeries, treatment procedures, prescription forgery and unperformed medical services.

"With the greater utilisation of health insurance in the emirate, cases of insurance policy manipulation are increasing. We therefore encourage residents to report suspected cases of fraud to the Health Authority Abu Dhabi (HAAD) for further investigation," Marwan Al Nabulsi, section head of enrolment and inspection at the HAAD, told Gulf News.

Since 2008, employers in Abu Dhabi have been obligated to provide mandatory insurance coverage to all their workers. Currently, 95 per cent of the emirate's population has mandatory health insurance.

According to insurance executives, manipulation or fraud can then occur in a number of ways, all of which result in negative consequences for beneficiaries. In 2011, the HAAD recorded more than 900 complaints; 34 of these cases were referred to the public prosecutors and six to the courts.

"One of the most common cases is when the health care provider makes a claim for excessive procedures," said Dr Jad Aoun, chief medical officer at The National Health Insurance Company (Daman), which currently has 2.1 million beneficiaries and investigated nearly 1,000 suspected cases of insurance fraud last year.

Certain insurance policies allow beneficiaries to claim only a certain amount each year for a specific type of treatment, such as dental procedures, Dr Aoun said.

"In this case, if the limit is exceeded due to overbilling by a provider, the beneficiary may not be able to claim further treatment in that speciality for a while, or may have to pay for it on their own," the medical officer added.

Administrative errors at smaller clinics also lead to duplicate invoices being filed, which eventually leads to more money having to be paid by insurance companies if the duplication is not detected.

"In the long run, any overbilling or unnecessarily prescribed treatment leads to inflation in the cost of health care. If this continues, insurance companies are forced to charge higher premiums, which may eventually lead a company to downgrade the level of coverage provided for its employees. In fact, the cost of insurance policies has been increasing at the rate of 15 to 20 per cent annually, and this is a real concern," said Dr Hazem Al Madi, chief executive officer of insurance company Green Crescent.

Inflated insurance premiums can also result when beneficiaries use insurance coverage to avail of cosmetic procedures that are not normally covered by their policies.

"Most insurance policies allow for a cosmetic procedure if the patient has suffered from a disfiguring accident or injury. So beneficiaries sometimes collaborate with their health care providers to get coverage for purely cosmetic surgeries that have no medical need. In fact, 30 per cent of the insurance frauds we detect each year stems from such instances," Dr Al Madi said.

He added that beneficiaries are also often unaware of the terms of their insurance policies.

In a case of suspected fraud, residents can either approach their insurance providers to file a complaint, or approach the Customer Service Department at the HAAD.

"After investigating a complaint, the court system issues a judgement for offenders that varies between fines, time served for the offenders and even deportation. In addition, the Health Professional Licensing Department also takes administrative actions to temporarily or permanently suspend the licence of any licensed health professionals convicted of fraud," Al Nabulsi said.