Is there a fraudster in the house?
In a street in Cameroon, Africa, lies the Holy Family Foundation Clinic. Here, for a period of 14 days, an insurance policy holder underwent malaria treatments worth more than 17,000 Danish kroner. But upon closer inspection, the clinic was closed, the stairs to the main entrance were overflowing with waste and there was not a single medical doctor for miles.
Every year SOS International receives some 500 inquiries from customers about alleged insurance fraud and this trend has risen by 20% since 2012. With a few dedicated employees, experienced doctors and dental consultants, as well as an extensive international network of partners, the investigation department of SOS International looks into suspected fraud cases on behalf of the Nordic insurance companies.
The investigation department of SOS International estimates that up to 1/3 of all cases can possibly be rejected and that discrepancies can be demonstrated in just as many cases. This way, SOS International provides insurance companies with the opportunity to save damages in 2/3 of all received suspected fraud cases.
From cholecystitis to liposuction
Investigative work is an example of how SOS International utilises medical, linguistic and network-based competencies and gets to the bottom in a number of cases in order to demonstrate a discrepancy and thus suspicion of fraud: "What we look at is, among other things, the correlation between the policyholder’s information and the medical reports. Are the diagnosis, treatment and period of hospitalisation consistent? Did the patient have an emergency or was the consultation booked in advance, and do the hospital and the doctor exist at all?” says Charlotte Ferkinghoff-Borg, who works as an investigator at SOS International.
And insurance fraudsters are very creative. From placing an extra zero on the medical bill to a "fall accident", which, in fact, covers a planned nose surgery:
"In a case from Jordan where the price of an acute cholecystitis was just under 37,000 Swedish kronor, our medical investigator confirmed that the acute diagnosis was consistent with both the price and the treatment. But when he dug a little deeper, it turned out that the patient's infection count was completely normal - and this is never the case with acute cholecystitis. It turned out that the patient had undergone a liposuction procedure, and that the hospital had helped the patient get another patient's journal!” says Charlotte Ferkinghoff-Borg, investigator at SOS International.
The Usual Suspects: Diagnoses that may conceal another treatment, e.g., plastic surgery or non-urgent problems:
- Herniated disc
- Fracture of the nose
- Eye surgery
- Fertility treatments
Increasing fraud in Russia and girls under the age of 18 under the knife
Over the past three years, Russia has risen high on the list of countries in which SOS International has proved fraud. Also, the Middle East, for example Pakistan, Iran, Afghanistan and Iraq, and Africa, for example Cameroon and Kenya, have been moving up over the past three years. After a few years of standstill, fraudulent activities have once again been registered in Egypt, and in the first half of 2016 there has been an increase in cases from Brazil.
In general, an overrepresentation of men is observed in connection with insurance fraud, whereas women have a greater tendency to commit travel insurance fraud, as figures from SOS International's investigation department show. While men are more likely to forge documents, women cheat with, for example, cosmetic treatments. Over the past three years, we have seen something completely new - cosmetic treatments in patients (girls) under 18 years of age, while, for example, there is almost no document forging or plastic surgery fraud in the age group 60 years or more.
Timed and orchestrated stories
A typical characteristic of fraud cases is that the communication between the policy holder, the company and SOS International is kept to a minimum:
"We have witnessed the policyholders contacting neither the company nor SOS International in case of an emergency. If they do, they may subsequently be difficult to get hold of and may have arranged everything themselves. On the whole, the course of their disease has turned into a good story, which is timed and orchestrated. Perhaps they have lost important documentation or paid the bill in cash and so, unfortunately, we cannot follow the money, even though we live in a digital age. This, of course, confirms our suspicions,” concludes Charlotte Ferkinghoff-Borg.
When the warning lights are flashing – typical cases that arouse suspicion
- Cases reported after arrival home
- Expensive cases
- Injury date close to the date of departure or return
- Treatments that could be plastic surgery, infertility treatment or scheduled routine and health checks
Facts about the investigation department of SOS International
SOS International conducts investigations across the Nordic countries. Medical and dental consultants with excellent language skills affiliated with the department. In addition, there is a strong international network which, among other things, operates as agents on site. SOS International investigates and uncovers the medical evidence in a case and then comes with a recommendation based on this evidence. Case processing takes anything between one day and several months, depending on the nature, complexity and the area of the world in which SOS International works.
If you would like to take advantage of SOS International's investigative service, please contact your Key Account Manager.