Health Claim Investigation Services

Health-Claim-Investigation

Health Claim Investigation Services

Health insurance fraud is one of the fastest-growing threats to the insurance sector. Fraudsters exploit gaps in the system through fake hospitalization claims, inflated billing, non-existent procedures, fabricated disabilities, and collusion with service providers. These activities not only drain resources but also undermine the trust between insurers and policyholders.

CLAIMLAB’s Health Claim Investigation Services are crafted to detect, document, and deter fraudulent or exaggerated claims through fact-based field and digital verification techniques. Our investigations cover a broad range of scenarios: from short-stay hospitalizations to long-term disability claims and accidental injury verification.

We evaluate each claim with clinical, procedural, and documentary scrutiny, ensuring that each submitted record—from bills and prescriptions to lab reports and consultation slips—is genuine, medically justified, and policy-compliant.

Our team works closely with the insurer’s Claims, Underwriting, and SIU (Special Investigative Units) to deliver evidence-backed, legally valid, and actionable reports that uphold the company’s financial and legal interests. Whether you need confirmation of a surgery, test, treatment, or incapacity, we provide ground-truth clarity.

What We Do

  1. Document & Billing Verification
    • Analyze hospital invoices, prescriptions, diagnostic reports, and discharge summaries.
    • Check for inflated costs, duplicate billing, or forged entries.
  2. Hospital & Provider Cross-Verification
    • Contact providers to confirm admissions, procedures, and attending physicians.
    • Visit hospitals and labs to validate services.
  3. Pre-Existing Condition Review
    • Compare revealed medical history with policy-declaration records.
    • Identify undeclared or suppressed health conditions.
  4. Provider & Lab Interviews
    • Interrogate treating doctors and diagnostic staff to confirm treatment authenticity.
  5. Surveillance for Disability Claims
    • Observe daily activity of claimants in cases of alleged incapacity, ensuring alignment with claimed disability.
  6. Cross-Provider Data Matching
    • Confirm medical procedures through multiple independent sources (e.g., labs, ambulance records).
  7. Digital Validation Tools
    • Utilize geo-tagged photos/videos to verify onsite visits.
  8. Comprehensive Reporting
    • Deliver a conclusive report supporting internal or external audit review.

Benefits

  • Detects fraudulent, exaggerated, or fictitious medical claims
  • Reduces claim leakage and financial drain
  • Improves underwriting by flagging high-risk behaviors
  • Strengthens compliance for IRDAI guidelines
  • Provides clear, actionable data for claims teams

Verification methods

  • Telephone or field verifications with treating staff
  • Site visits to hospitals and labs
  • Surveillance of physical health claims
  • Cross-verification of procedures and tests
  • Geo-tagged photo/video evidence
  • Policy vs. health-declaration checks
  • Timestamped, structured investigation reports

Other Services