Insurance companies are finally cracking down on benefits fraud

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Pradip Rodrigues

Last week the TTC and insurance company Manulife announced a settlement of a 2016 lawsuit related to a widespread benefits fraud which resulted in 223 TTC employees losing their jobs. Ten people were convicted in a wide scheme involving employees submitting false medical claims and sharing profits and in turn receiving products they were either not entitled, cash or both.

What can happen when employees brazenly misuse their benefits and take things too far can serve as a cautionary tale to so many otherwise great employees with wonderful work records. All it takes is one service provider to be investigated and all clients that have benefited will have their reputations sullied. Companies are now willing to dismiss employees who’ve been found guilty of insurance fraud.

The average desi working at a company that offers generous employee benefits either knows someone misusing their benefit plan or are themselves doing so in some way or the other. It is seen as a low-risk crime where no one gets hurt and many employees who misuse their benefits often justify it by pointing out that they pay hefty premiums and are therefore entitled to using (abusing) or profiting through their benefit plan. Of course, they need that ‘orthotic’ pair of shoes or that pair of designer sunglasses…

A Canadian Life and Health Insurance Association study a few years ago found that for every $10 spent on healing a patient, anywhere from 20 cents to one dollar is lost to corruption. Canadians spend around $200 billion every year on health care—70 per cent in the public system and 30 per cent in the private sector. Insurance fraud, in other words, is a $20-billion industry in Canada.

Recently my optician was telling me that several South Asian opticians are under investigation for fraud and quite a number have already shut down.  There is a crackdown on benefit fraud and insurance companies are now going through all claims more closely. Better technology is allowing insurance companies to study patterns and make links more accurately and bring the guilty to book. My optician seemed wary of investigators posing as customers and is very careful about what he says and does.  

Many insurance providers encourage their clients to ensure the service provider has not been de-listed by the company for wrongdoing  and warn that dealing with them would lead to their claims being denied. I recently looked at one such list and it was long, and I have to say that most of the blacklisted service providers happened to belong to one of two immigrant backgrounds. No prizes for guessing which two.

In 2011, a group of medical practitioners in Mississauga exploited recently landed immigrants who were unfamiliar with the Canadian health care system. They convinced newcomers to hand over their login information for their insurer’s website, which allowed them to steal the reimbursements.

I have heard stories where some employees hand over their benefit information to a service provider who then submits fraudulent claims to insurance companies on their behalf, in return the employee gets a few hundred dollars, depending on the annual limit. There are any number of service providers who spend a good part of their day submitting claims for services they’ve never provided.

Not so long ago, I received a call from a new immigrant who had just landed a decent job with great benefits. Her mother was visiting had some back pain and needed a massage therapist. The new immigrant wanted an RMT specialist who would be willing to provide receipts in her name so she could be reimbursed. I told her that I didn’t know anyone who would take such a risk. She was also hunting for someone who could make her mother new designer sunglasses.

I was quite appalled to discover that this otherwise prim, law-abiding woman who is known to be quite religious was willing to cheat the system. I couldn’t help her, but later she told me she found many providers who happily got her mother not one pair of sunglasses, but also a pair of prescription reading glasses. An RMT she found not only ensured her mother received a massage every week of her stay but also encouraged the employee and her husband to relax and have massages as well to relieve ‘back pain’ as often as they liked. That part came out of her seemingly unlimited physiotherapy coverage, a kind doctor obviously obliged with a prescription. Oh yes, life is good. And just how did she get in touch with this obliging network? Another desi co-worker pointed her in the right direction. I am guessing she also has some premium orthopedic pillows that ensures a good night’s sleep!

Call it racial profiling, but insurance companies are now seeing a pattern of fraud and there are scores of opticians, RMT therapists, physiotherapists etc. under the radar and unlike in the past when employees could simply say they were not aware just does not cut it. Employees who wilfully participate in fraudulent schemes in order to get expensive custom orthotic shoes, pillows and other services they do not require or deserve need to hit pause.

It is one thing living as NRIs in Canada and pointing out that India is a corrupt country, it is quite another when it is so easy to point out that Indians are generally a corrupt people wherever they go. -CINEWS

Comments: 1

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  1. India is a corrupt country, it is quite another when it is so easy to point out that Indians are generally a corrupt people wherever they go.
    Shame on you Pradip calling Indians Corrupt