First of all, the following claims are the easiest to investigate
1. Take risks in a short time after insurance, such as critical illness insurance and medical insurance, and take risks just after the waiting period, and apply for critical illness claims and medical claims. In order to rule out the possibility of insuring against diseases, the insurance company will certainly investigate the case.
2. Frequent accidents are a common problem of subsidized medical insurance.
For example, the insured was hospitalized for frequent accidental injuries within one year before applying for subsidies from several reimbursement companies. The insurance company will suspect that the insured intentionally defrauds the insurance to obtain a large amount of allowance compensation, and will file an investigation.
3. The insured amount is huge, such as high critical illness insurance, life insurance and high accident insurance. This kind of insurance fraud is more likely. Of course, insurance companies will carefully investigate and check customers' insurance motives from their balance sheets. For example, do you owe a large foreign debt?
4. There is obviously an undisclosed past medical history on the medical record. If there is an undisclosed past medical history on the medical record, such as kidney disease seven years ago, stomach surgery five years ago, dizziness for two years, etc. The insurance company will check the past medical history to confirm whether it is insured with illness.
5. Insure a large number of insurance companies in a short time. If someone has the intention of fraudulent insurance or sickness insurance, they may be insured in different insurance companies. When making claims, there will be cases where claims are made by multiple insurance companies at the same time. Therefore, for a large number of insurance companies in a short period of time, insurance companies will conduct in-depth investigations and sometimes conduct joint investigations.
Second, the main way for insurance companies to investigate medical history In the case of doubts in the process of claims review, if the insurance company decides to start the investigation procedure, it will notify the claims investigation team and send full-time investigators to start the investigation.
There are several ways for insurance companies to investigate claims:
1. Find the customer's past medical insurance usage records through social security records investigation, not only the local records of the residence, but also the social security records of the user's birthplace according to the attribution of the ID number. If the user's identity information also includes other work places, past residences, household registration records, etc. The medical insurance records of these places are also likely to be inquired.
2. Through the investigation of hospitals and medical institutions. In addition to the hospital where the accident occurred, the insurance company will also investigate the hospitals where the insured's residence and work place may go. Hospitalization records, outpatient medical records, imaging and biochemical test reports, prescription drug records, etc. It's all part of the investigation.