Anti-fraud initiatives protect your clients

The Co-operators is working with the Canadian Life and Health Insurance Association (CLHIA) to provide input into the anti-fraud task force within the Ontario Auto Association. This initiative is another way we are demonstrating our commitment to protecting your clients.

Why we joined the task force

It is important to work together across industries to combat fraud. We have found that people who commit auto insurance fraud often also target other benefit paying systems. The Anti-Fraud task force in Ontario recommends that both the government and the private sector collaborate on fraud prevention in order to prevent fraud in multiple benefit paying systems committed by the same fraudster. We want to ensure that fraud claims are reduced in Group Benefits in addition to Auto insurance.

How fraud affects Extended Health Care

Estimates indicate between 2-10 per cent of every health care dollar in North America is lost to fraud. In 2010, the Canadian life and health insurance industry paid out over $15 billion in supplementary health claims; that means the cost of fraud could surpass $1.5 billion each year.

We know that auto fraud plays a part in health care fraud but we are unsure of the total effect. Paramedical claims have seen a steady rise in fraud from both providers and plan members, and these types of claims could stem from auto claims.

How fraud affects disability claims

We have encountered a few fraudulent claims where a condition is completely falsified. We have found that prudent disability claims management at the onset of claim submission will bring our attention to claims that need to be closely scrutinized and investigated.

When disability claims resulting from motor vehicle accidents are approved, we must manage them stringently from the onset, knowing that they can often become prolonged. Our challenge is the opportunity for secondary gain through accident benefit insurance and litigation against the at fault party. Claimants represented by a lawyer may oppose our efforts to engage the claimant in return to work programs. Therefore, extended claim durations are typical for us in this sector and these types of claims are often the most difficult to resolve quickly. Streamlining of arbitration and court process would be very beneficial but currently impedes our effectiveness.

What’s next?

We are continuing our efforts at combatting fraudulent activities and expanding our research and partnerships.

Reformulary

Your Group Benefits clients have the opportunity to control drug plan spending and protect the sustainability of their Extended Health Care plan with a new evidence-based drug plan option.

Why one should consider Generic Drugs

Health Canada ensures that generic drugs are equivalent to brand-name options. Many factors contribute to the higher price of brand-name drugs, such as the cost of marketing and development.