Health Insurance Exaggeration of health insurance claims.

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mishmash

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A family member has come to me and has told me that he has received a letter from his health insurance which states that in respect of your claims for outpatient benefit, your claims have been selected for a routine audit. We will be in touch with the findings in due course.

He is extremely worried, he can’t eat, he can’t sleep and he is in a dark place and he has confided in me today he exaggerated some outpatient claims due to severe financial pressure at home.

The total he exaggerated came to around €2500. What will happen to him ? Will he lose his health insurance? Will he end up in court? He will pay it back but he needs to borrow it from someone. . Any advice appreciated.
 
So he defrauded an insurance company which puts the premiums up for everyone else.

Hopefully, they will pursue him and cancel his insurance.

Brendan
 
He should check the small print on his policy and depending on what this says, consider getting legal advice, especially if they have a policy of cancelling the policies of and/or prosecuting those found to have committed fraud in relation to a claim.
 
Yes I am thinking the company will cancel the insurance and obviously make him repay it but I haven’t said it to him. I just told him the audit will reveal all and then he will have to follow what the health insurance says to do.
elcato said:
Only advice I will give is start at the source of the problem. They can deal with the consequences of the other as it happens.
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yes things have improved but he’s afraid of losing his job going to court having a criminal record. And it’s his own fault but he said he was under severe pressure
T McGibney said:
He should check the small print on his policy and depending on what this says, consider getting legal advice, especially if they have a policy of cancelling the policies of and/or prosecuting those found to have committed fraud in relation to a claim.
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yes it says in the fine print that the policy will be cancelled and any benefit under the policy will be forfeited. Also the health care company reserves the right to refer the matter to the relevant authorities.
 
mishmash said:
Yes I am thinking the company will cancel the insurance and obviously make him repay it but I haven’t said it to him. I just told him the audit will reveal all and then he will have to follow what the health insurance says to do.

yes things have improved but he’s afraid of losing his job going to court having a criminal record. And it’s his own fault but he said he was under severe pressure

yes it says in the fine print that the policy will be cancelled and any benefit under the policy will be forfeited. Also the health care company reserves the right to refer the matter to the relevant authorities.
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Hopefully it won't come to that. Best wishes to him.
 
Good morning. He has decided to ring the health insurance company, confess and pay back all he received in claims. I told him to receive legal advice and to think long and hard about it but he said he can’t sleep and he can’t do anything while this is hanging over him. He said he is completely in the wrong and wants an end to it. He said as each day passes it’s worse and he knows that the company will find out what he has done. Any advice appreciated
 
mishmash said:
Good morning. He has decided to ring the health insurance company, confess and pay back all he received in claims. I told him to receive legal advice and to think long and hard about it but he said he can’t sleep and he can’t do anything while this is hanging over him. He said he is completely in the wrong and wants an end to it. He said as each day passes it’s worse and he knows that the company will find out what he has done. Any advice appreciated
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He'd be best off getting legal advice before confessing to them but if he's hell bent on making a confession anyway, you should try to coach him to do so in such a way that he will not incriminate himself. If you or someone else can be with him when he makes that call, all the better.
 
He should wait and see what they have to say first, and make no comment thereafter, until he, if necessary, needs to get a solicitor. The audit is probably a fact finding mission.

In light of the initial reference 'He will pay it back but he needs to borrow it from someone' he could land up in a lot more debt with solicitor's costs as well.

Forewarned is forearmed.

Do feel very sorry for him but he needs to stay calm and I know that's easier said than done.
 
Yes I’ve told him to go to a solicitor and to see what the solicitor advises. He just wants to pay the money back and if the health insurance is cancelled so be it. But he’s petrified it’ll end up in court.
 
Just a coda to this, if they do decide to severely penalise him, he should appeal whatever they propose, but to do this properly and to do himself justice he'd need either legal advice or the assistance of someone well versed on the conduct of adversarial proceedings. For example a retired school principal or someone with union shop steward experience might be happy to do him a favour.
 
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He did a stupid thing, haven't we all.

Now he plans on doing another stupid thing.

mishmash said:
He has decided to ring the health insurance company, confess and pay back all he received in claims.
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What does he expect the Insurance Company to say in response, 'thanks that will be fine so'.

He should sit and do nothing until he hears from the Insurance Company.
mishmash said:
We will be in touch with the findings in due course.
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Then he should see a solicitor. Then take the solicitor's advice.

mishmash said:
He is extremely worried, he can’t eat, he can’t sleep and he is in a dark place and he has confided in me today he exaggerated some outpatient claims due to severe financial pressure at home.
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Tell him to get a grip.

mishmash said:
The total he exaggerated came to around €2500. What will happen to him ?
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Perspective.
 
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