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Crime and Fraud
Friday, December 1, 2006
Still trying

The value of fraudulent claims submitted to the life insurance industry during the first half of this year dropped by almost R76m compared to the first half of last year, from R175,2m to R99,5m.

Lerato Mametse, communications manager at the Life Offices’ Association (LOA), says the reduction in claims fraud from January to June this year was a welcome respite after fraudulent claims spiked by almost 40% last year compared to 2004.
She says while claims worth R99.5m were rejected in the first six months of this year because of fraud or other irregularities, life companies settled claims worth R70,9 billion in the first six months of this year, an increase of 7% on 2005.
“While it is the business of life assurers to pay claims, it is important that companies apply strict underwriting and claims assessment procedures to make sure that honest policyholders don’t end up subsidising those that are dishonest. The higher the claims experience of life companies, the more likely they are to push up premiums to cover the perceived increase in risk.”
Mametse says the life industry noticed a significant reduction in broker involvement during the first half of this year. Only 105 cases of fraudulent claims worth close to R500 000 involved intermediaries, while three times as many cases worth R4,4m had been recorded the year before over the same period.
Mametse says while the incidence of claims fraud seems to be on the decrease overall, material non-disclosure continues to plague the industry.
Life insurers rejected some 682 claims to the value of R68,6m in the first half of this year because of material non-disclosure where policyholders had failed to reveal important information about a serious medical condition such as cancer or their lifestyle (for example, participation in dangerous pursuits like skydiving). During the first half of last year, life companies had rejected some 763 cases for material non-disclosure, but to a much lower value of R55,2m.
“It is generally accepted that the applicant knows more about the risk to be insured than the insurer. For this reason the law compels applicants to disclose all information likely to influence the appraisal of the risks involved, therefore being able to apply the appropriate policy terms and premiums.”
Mametse says facts generally regarded as material include age, medical history, state of health, family medical history, and financial status.
“One of our member companies reported a case of material non-disclosure, where life cover worth R1,1m was taken out on the life of a person who was on a ventilator and in intensive care at the time of the application. Since this was not disclosed to the life company, the claim was rejected as it would not have insured the person if all the facts had been known.”
She says in another case the applicant stated in his application for life cover that he was employed as a clerk earning R5 500 a month, when in fact he was unemployed and dying of TB. Again, the claim for death benefits was rejected.
But while the increasing incidence of non-disclosure continues to worry the industry, fewer people were guilty of misrepresentation by not fully disclosing the seriousness of a medical or lifestyle condition on application for a life, disability or income protection policy.
In the first half of this year the industry recorded 437 cases of misrepresentation worth R18,9m, while in the first half of last year 476 cases worth R95,8m.
Mametse says claims involving the use of fraudulent documentation reduced in financial terms from R18,2m in the first half of last year to R10,1m in the first half this year, although the number of cases recorded almost doubled.
She says a father and daughter team has just been sentenced to a prison term of seven years for fraud and forgery after they submitted a fraudulent death claim in Gauteng earlier this year.
“The accused father and daughter had taken out a personal accident and funeral policy on a person they alleged to be the daughter’s husband, while he was, in fact, one of their tenants. When this person died three months later of natural causes excluded in terms of a waiting period imposed by the policy, they fabricated information to show that the insured had died of an unnatural cause. But since they used death documents for a pauper killed during a burglary under investigation by police, the life company discovered that the claim was fraudulent.”
Mametse says dishonest beneficiaries and criminal syndicates were involved in 55 cases of claims fraud from January to June this year, compared to only 17 cases last year. The claims amount involved was, however, slightly lower this year than last year at R1,4m.


Copyright © Insurance Times and Investments® Vol:19.6 1st December, 2006
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