Montreal French-language publication, La Presse, reported Aug.22 on a fraud against Great-West Life by employees of a Shaw Direct office in Montreal perpetrated during 2011 and 2012. According to police, the fraud involved some 80 employees who were suspected of making fictitious or exaggerated dental benefit claims totalling $693,675 under their group insurance plan.

Great-West Life told The Insurance and Investment Journal that the company has developed and implemented sophisticated features for the prevention and detection of insurance fraud. These features include systems controls and investigative capabilities, stated Jeff Macoun, executive vice president, group client, Great-West Life in an email.

Macoun said that fraud can impact the premium that employers and employees pay for their group insurance plans. The insurer says it is working hard to eliminate it. Macoun says the company’s Special Investigations Section includes former police officers who have received training in investigative techniques and evidentiary requirements. In some cases, its investigative methods also include the use of undercover operations conducted by private investigative firms, he added.

A large-scale phenomenon

In North America, the Canadian Life and Health Insurance Association (CLHIA) estimates that fraud accounts for between 2 per cent and 10 per cent of the cost of health care," said Lyne Duhaime, president of CLHIA-Quebec and senior vice-president nationally. "It's huge, considering the amount of the claims," Duhaime said, adding that this results in higher costs for all.

She said that CLHIA members offer complementary health insurance to 24 million Canadians and pay more than $30 billion annually for health care services provided in Canada: $10.7 billion in drugs; $7.8 billion in dental care; $ 3 billion in paramedical services and visioncare; $1.8 billion in hospital care; $0.8 billion in out of the country care.

Measures to be taken

Signs of fraud on health care can be subtle and difficult to spot, says Duhaime. The CLHIA is calling for all stakeholders to be vigilant. "The industry recognizes that reducing fraud and abuse in health care is a team effort. We work closely with health professionals, clients and law enforcement to provide tools and education to limit fraud,” she said.

Duhaime said that witnesses of insurance fraud can report it via the CLHIA website.