Foreign Claims Review Consulting Service

ATTENTION! CLAIMS EXAMINERS AND INVESTIGATORS IN INSURANCE OFFICES, HMOs AND TRAVEL COMPANIES IN THE UNITED STATES, CANADA, EUROPE AND ASIA

… Before you pay that life, health insurance (including medical expenses) and travel (money and baggage) claim let us assist you examine the facts. Let us act as your in-house Claims Examiner for:

  • Life
  • Health
  • Travel Claims

THIS SERVICE IS AVAILABLE ON CONTRACT BASIS ONLY

We would provide the Claims Examiners the benefit of international experience of 32 years (since 1979) investigating fraudulent life, health insurance and travel claims (medical expenses, trip interruption, accidental death benefits, baggage and personal effects losses).

We are aware that millions of fraudulent life, health insurance (including medical expenses) and travel (money and baggage, etc) claims originating overseas continue to be filed with insurers, health maintenance organizations (HMOs) and travel insurance companies in the United States, Canada, Europe and Asia every year. Most of these claims are paid by these organizations and companies because they do not know that the claims could not be authentic.

The review service has thus been established to assist insurers, HMOs and travel companies’ Claims Examiners review claims originating from Africa, Asia, South America, North America, Europe, Middle East, Caribbean, Australia and Central America and filed with their companies and thereby minimize payments on fraudulent claims.

Our estimation is that over 20 million bogus life, health insurance (including medical expenses) and travel (money and baggage loss) claims originating from Africa, Asia, Eastern Europe, South and Central America, alone are filed with insurers, HMOs and travel insurance companies in the United States, Canada, Europe and Asia every year. We estimate that in less than 100,000 claims the companies order on-the-spot investigations to know the facts. In the rest, the companies’ in-house examiners review them, most of them inadequately, and thus pay the claims.

Consider these cases
  • • From 1989 to 1996 a U.S. insurer paid over US$31,000.00 in health claims to a claimant following alleged hospitalization and treatment, some for one-day inpatient attention in Kenya, East Africa. The claimant filed subsequent claims for 1998, 2000 and 2001 totaling over US$21,000.00. The treatments allegedly took place in several clinics with each alleged attending physician appending a stamp indicating that he is a holder of Diploma in Clinical Medicine. Clearly, this was an indication that the persons are not full-fledged medical practitioners as the holders of the qualification in the country only have three years of medical education and are called Clinical Officers (like Medical Assistants) and are not bona fide physicians or medical doctors. These claims therefore ought to have been repudiated ab initio as the insurers were not concerned with treatment by non-fully licensed medical practitioners. But this fact was not known to the Claims Examiners whose office had paid over US$31,000.00 before the frequent claims led them to seek on-the-spot investigation in 2001. Our investigations proved that the Clinical Officers simply fabricated the documents presented to the insurer.
  • • In 2005, an Indian citizen resident in the United States filed a claim with an insurer in the U.S. alleging that she was hospitalized and treated for enteric fever for 5 days in June 2005 and was billed over US$13,000.00. The claim documents presented to the insurer showed that the alleged attending physician held the qualification B.A.M. This refers to Bachelor of Ayurvedic Medicine degree. Such a practitioner is not an orthodox medical practitioner. But while this fact ought to have led the Claims Examiners to repudiate the claim, they paid it straightaway. This led the claimant to file a subsequent claim alleging hospitalization and treatment in the same establishment in April 2006. She submitted documents purporting that she paid over US$10,000.00. The insurer decided to investigate this and the previous claim. Our on-the-spot investigation in India revealed that both the alleged ayurvedic medical practitioner and his establishment were non-existent.

  • • In October 2003, we received four assignments from a United States insurer. They involved two family members and four different hospitalizations in 2002 and 2003. The insured had filed a claim in 2002 alleging that while on a trip to Cameroon, Central Africa, he was hospitalized on two occasions, first for malaria for 12 days and later for typhoid fever for 10 days. The total amount of the bills for the two alleged hospitalizations was the local currency equivalent of US$18,000.00. The insurer had paid these claims. Thus, the claimant encouraged by this, filed another claim in 2003, this time alleging that his daughter was hospitalized twice in the same hospital, first for chicken pox for 10 days and again for pneumonia for 7 days and billed the local currency equivalent of about US$13,800.00.

    On our review of the 124-page documents according to the terms of our Foreign Claims Review Consulting Service, we noted several indications that the documents were fabricated by one person at once and were not documents completed in the course of actual hospitalization. However, before we could conclude and report on our review, the insurer went ahead and paid the second claim totaling US$13,800.00 in spite of our assurances that the claims cannot be authentic. Apparently, they were swayed by the enormous volume of documentation presented to them, the same factor we had considered as a red flag to indicate that they were contrived. There were over 20 red flags from our reviews to show that the documents were entirely fabricated which included that the dates therein were in the American style. For instance, the date May 20, 2003, was written as 5/20/03 whereas in Cameroon the date would be written as 20/5/03.

    On receipt of our review note, the insurer asked for on-the-spot investigation in Cameroon to determine the facts. Our investigator in Cameroon was bewildered at how his findings fitted our review notes to the insurer. Our investigation revealed that both the “hospital” and “physician” were non-existent.

    By December 2006, the claimant was still being prosecuted in the U.S. for filing fraudulent claims and for mail fraud.

  • • In 2005, we received an assignment from a United Kingdom travel insurer to investigate alleged theft of their policyholder’s baggage while in transit in Lagos, Nigeria. The insured had alleged that he boarded a taxi from the Murtala Muhammed International Airport, Ikeja, Lagos, but on the way the driver pushed him out of the vehicle and sped away with his luggage. This incident happened on April 8, 2005. According to the policyholder, he then went home but four days later, went to the court and swore an affidavit alleging ownership of the stolen luggage. That same day, he took the sworn affidavit before the Police for them to issue him their extract (of course, not their report since they did not investigate the matter and cannot now do so after four days). The Police were bound by statute to provide the extract which they did even if they had doubts whether the incident indeed occurred or not. Both the affidavit and police extract were submitted as proofs of the alleged theft to the insurer for them to pay a claim of over ₤6000.00! Of course, the circumstances did not meet commonsense test. Since 1979, this circumstance has been replicated in several hundreds of baggage loss investigations handled by us throughout East, West and Central Africa for travel insurers in the United Kingdom and Canada.

    As usual, our on-the-spot investigation in this case revealed that the entire circumstance was the claimant’s imagination, contrived with an ulterior motive to be paid unmerited benefits.

Here is a service that we help the insurance industry in the United States, Canada,
Europe and Asia identify false and bogus foreign health and travel insurance claims.

FOR THIS SERVICE WE OFFER THE FOLLOWING:
  • • We would review red flags in foreign/international life, health insurance (including medical expenses) and travel (money and baggage, et al) claims documents originating in any country around the world.
  • • On receipt of the documents submitted as documentary proofs on each claim, we would review them within 7 days and provide the detailed red flags.
  • • For health insurance or medical expenses claim, we would further review them alongside the “the 40 plus indicators for Investigation Scale” and arrive at a score which would suggest to the Claims Examiner whether to pay the claim straightaway or subject it to on-the-spot investigation. The final decision would be up to the principal.
  • • If need be we will have our Medical Consultant, a physician in practice in the country of origin of the claim, review the documents presented to the office in regard to their appropriateness in relation to the condition or illnesses treated; the medical necessity for the hospitalization and treatment; and the usual, customary and reasonable charges for such treatments in the country.
  • • We would after the review send a detailed report by email or fax within 7 days of receipt of the claim documents to the Claims Examiners.
  • • We would review investigative reports of other investigative agencies and provide the Claims Examiner with a review note. If further action is required, we would list what should be done.
  • • By assisting in-house Claims Examiners we would be providing them the benefit of 33 years international life, health insurance (including medical expenses) and travel claims investigative experience. This would entail that over time, the Examiners would garner the requisite experience to be able to review these claims independently.