How SOS International detects insurance fraud
Recently, Swedish media carried the story of a woman who had defrauded her insurance regarding a hospital admission abroad. The disclosure resulted in the woman being given a suspended sentence. But how do you detect insurance fraud? We asked Karina Nordmann Østrup, who investigates such cases at SOS International.
Exaggerations and false information about hospital admissions are some things they experience in the investigation department of SOS International. Using a global network and extensive experience, they help insurance companies solve suspected cases of fraud abroad. The department works mainly with medical cases but can also assist with other matters, such as checking receipts from local shops and police reports.
When fraud is suspected
There can be many reasons why an insurance company finds a case suspicious, and the more years of experience in the industry, the better you are at recognising the signs of possible fraud.
“When an insurance company contacts us, it’s because they have a suspicion. Sometimes they have a lot of evidence, while in other cases it’s a feeling that something is not right,” says Karina Nordmann Østrup, Investigation Coordinator at SOS International:
“One example we often see is cases that are reported as a treatment for an acute injury, but where the insurance company suspects that it is, in fact, a cosmetic operation that the customer is trying to get the insurance to pay for.”
When SOS International receives an enquiry from the insurance company, it can be either a summary of the suspicion or a more detailed account of the course of events. The company then transfers the case to SOS International, which takes the investigation further.
The investigation gets underway
When it comes to investigating fraud, there is no “one size fits all” solution, and each case is different and therefore requires its own approach.
“In the example of cosmetic surgery, the investigation may involve our in-house doctors assessing whether the surgery in question is a realistic treatment for the claimed injury. Or whether the doctor listed as a practitioner works in a clinic that only performs cosmetic surgery,” explains Karina Nordmann Østrup.
Furthermore, Karina Nordmann Østrup explains that they examine the validity of customer documents. Do logos and fonts match other documents from the same institution? They also have a price list for treatments in different countries, which can help you decide whether the price quoted is realistic.
Collaboration speeds up the process
“We can’t solve a case alone. We have an extensive network of partners worldwide who can help, for example, obtain information from the local health service or police. We can then compare this information with the information the customer has provided to the insurance company to determine whether or not there is fraud,” says Karina Nordmann Østrup.
Once SOS International has completed its investigation, it sends an objective report to the insurance company that filed the claim. It is then up to the individual company to decide whether the cover should be paid or rejected or whether it is a criminal act that should be reported to the police.
In the example of cosmetic surgery, the investigation may involve our in-house doctors assessing whether the surgery in question is a realistic treatment for the claimed injury. Or whether the doctor listed as a practitioner works in a clinic that only performs cosmetic surgery