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Health insurers crack down on bogus claims

Health insurers are cracking down on claims generated in foreign countries

(Keystone)

Swiss health insurers are cracking down on holidaymakers who return home from trips abroad with claims for fictitious medical bills packed in their luggage.

CSS, one of Switzerland's largest health insurance firms, has set up a dedicated foreign claims division to handle receipts issued outside the country.

CSS receives around 30,000 claims every day. All are checked and those that do not originate in Switzerland are passed on to the newly created division for further investigation.

The company says it uncovers “at least” two bogus claims a week, but adds that the number increases in the summer months when more people take trips abroad.

"This is a problem that does not only affect CSS," said Esther Vogel, head of the overseas claims division at the firm.

"Other health insurance companies also have problems with fraudulent claims," she told swissinfo.

Legal proceedings

Last week CSS confirmed that it had launched legal proceedings against a private clinic in the Serbian town of Kragujevac.

The health insurer alleges that doctors at the clinic issued medical bills to CSS clients for operations which never took place.

“This is a clinic with no more than six to eight beds which has been issuing bills for operations which are in part extremely complex,” said CSS spokesman Stephan Michel.

Five CSS clients who submitted bills from the clinic also stand accused of attempting to defraud the company.

“Claimants think there is easy money to be made because they are under the impression that insurance companies do not have the means to investigate whether foreign documents are genuine or not,” said Vogel in a recent interview with Swiss television.

“But they are wrong. We have an international network at our disposal to check such documents.”

Dedicated team

Rival health insurer Swica says it also routinely examines all bills which are issued outside Switzerland.

“Any claims containing receipts from abroad which we are concerned about are sent to our dedicated team of specialists,” said Swica spokeswoman Nicole Graf.

Claims of more than SFr5,000 ($3,900) are closely examined, but other criteria – including the country of origin of any receipts submitted – are also taken into account.

“Our experts ask themselves if the bills look plausible or… if people are sending in receipts for several operations or courses of treatment which appear to have taken place over a short space of time,” said Graf.

Swica says it also relies on information supplied to it by Medicall, the 24-hour assistance service which claimants are obliged to use when seeking medical help abroad.

Accidents abroad

Accident insurance companies report that they are also having to deal with cases of clients submitting false documents.

Erich Wiederkehr, spokesman for Switzerland’s largest accident insurance company, Suva, said rigorous checks were made on all foreign documents submitted.

“Claims which stem from an accident abroad are systematically examined and checked to determine whether they are genuine or not,” Wiederkehr told swissinfo.

But Suva says it is protected “to a certain extent” from bogus claims by the fact that anyone who submits documents has to prove that they have sustained a physical injury.

“With accidents, there is usually a visible injury to the body. This makes it easier for us to check claims, something which is more difficult for health insurance companies,” said Wiederkehr.

The company says it has on occasion even hired private detectives to follow and secretly film individuals in a bid to determine whether the accident injury they claim to have suffered is genuine.

“The Federal Court has authorised the use of video material as evidence… but we do have very strict rules regarding the protection of an individual’s privacy.”

swissinfo, Ramsey Zarifeh and Elizabeth Meen

In brief

Swiss health insurer CSS is taking legal action against a Serbian clinic for allegedly furnishing some of its clients with receipts for operations that did not take place.

The health insurer has recently established a foreign claims division to investigate receipts and bills which are issued outside Switzerland.

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