Are Hospitals Misusing a Patient's Medical Insurance?


Are Hospitals Misusing a Patient's Medical Insurance?

The last few years have seen a positive change in people's outlook towards health insurance. While, on the one hand, more and more people understand the importance of health insurance and are moving towards buying policies, there has been an increase in the number of health insurance frauds in India. It may come as a surprise to you that as per a recent Insurance Fraud Survey 2023 by the well-known company Deloitte, almost 60% of insurance companies in India are witnessing a steady increase in fraud in health insurance. Let us delve a little deeper into this topic. 

Health Insurance Frauds in India 

Health insurance fraud is when a procedure or treatment is rendered, even when it is medically unnecessary. It is done to over-utilise the care/ service so that patients/ insurance companies can be charged a higher amount. The potential offenders range from hospitals to doctors, vendors to pharmacists. That’s not all sometimes, health insurance fraud examples can also be seen where patients or policyholders file false/ misinterpreted claims in order to get a bigger reimbursement from the health insurance provider. 

Health insurance frauds in India are burdening health insurance companies and policyholders alike. The list below shows some of the top 10 insurance frauds in India:

  • Billing for services that are not a part of the coverage
  • Billing for services taken in an unauthorised hospital/ healthcare centre
  • Falsely reporting treatments 
  • Misinterpretation of the location of the service
  • Overutilisation of coverage
  • False issuance of medicine prescription
  • Misinterpretation of dates and location

Are Hospitals Misusing a Patient's Medical Insurance?

There have been some instances where hospitals have been found guilty of issues regarding medical insurance misuse. Some of such health insurance fraud examples can be seen in:


Sometimes hospitals charge for services or procedures that have either not been provided, or they exaggerate the level of treatment/ care given, with the aim to increase reimbursement.

Unrequired Services/ treatment

Sometimes doctors/ hospitals may prescribe/ perform numerous unnecessary tests and procedures in the name of detailed investigations. Certain treatments are given solely for financial gain without considering the patient's actual medical needs. Cases of prolonged hospitalisation only to jack up the expenditure are also quite common. 


It is also seen that while hospitals buy prescription drugs at much-discounted prices, they do not offer any such levy to the patients/ health insurance companies. 


A significant expense goes towards single-use items, also known as consumables. When it comes to consumables, the choice of each item, such as tissues, cotton, housekeeping items, etc. depends on the hospital. As the brand of every item may differ from time to time, the price range can often be manipulated by hospitals. 

Health Insurance Problems and Solutions

When we want to deal with health insurance problems and solutions, it is imperative that all the parties involved are more careful and cautious. As a prized policyholder with Care Health Insurance, we wish to keep you informed about every single detail of your health insurance policy. While we are there with you every step of the way throughout the insurance journey, we urge all the Care Health Insurance policyholders to keep a watchful eye and prevent any such health insurance frauds.

How to Prevent Health Insurance Fraud 

Keep in mind the tips given to steer clear of any instances of frauds in health insurance:

  • Always invest in a health insurance policy from a reliable and trustworthy health insurance provider
  • Avoid going for services or coverage that seems too good to be true
  • Understand the coverage and the exclusions of your health insurance policy. You should know what expenses will be covered by your insurer and what will be out-of-your-pocket
  • Make sure to keep your health insurance policy papers and health insurance card safely. In case it is lost, report it immediately
  • Understand the claim procedure. Inform us on time and see to it that the formalities, such as pre-authorisation, are completed
  • Make sure to never sign an incomplete claim form
  • Keep a careful check on all the procedures that are being conducted. In case you have any queries, do not hesitate to ask. You have the right to know all the details of your treatment
  • If someone from the hospital or outside tells you that they can get you special discounts on the bill, beware; it could be a fraudulent activity. Report it to the hospital authorities at once
  • In case a health insurance agent/ executive comes to meet you, make sure to check their ID and confirm the same with the company.

Let’s Conclude

Lack of awareness and education and scarcity of resources are some of the main problems of health insurance in India. However, the rising medical inflation and increased costs of treatment have made us understand what is the importance of insurance. 

It's important to note that these instances do not suggest that all hospitals or healthcare providers misuse insurance policies and are a part of health insurance frauds in India. However, if you, as a policyholder or a patient, suspect that your medical insurance is being misused, you need to know how to report health insurance fraud. Make sure to always review your medical/ hospital bills, understand the available insurance coverage, and get in touch with the hospital or the insurance company or both so that any discrepancies or concerns can be seriously dealt with. 

>> Also Read: How to Stay Away from Fraud in Health Insurance


1. The above information is for reference purposes only: Policy Assurance and Claims at the underwriter's discretion.

2. All plan features, benefits, coverage, and claims underwriting are subject to policy terms and conditions. Kindly refer to the brochure, sales prospectus, and policy documents carefully.


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