Health-benefits fraud happens every day — and it has real consequences

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Stephen Frank is chief executive officer of the Canadian Life and Health Insurance Association, a not-for-profit membership-based organization that represents 99 per cent of Canada’s life- and health-insurance companies.

It was recent front-page news that a leading hospital in Toronto fired 150 employees for a massive health-benefits fraud scheme. The scheme involved false claims from employees for things such as orthotics, compression stockings and physiotherapy, totalling upward of $5-million. While this grabs headlines, the unfortunate reality is health and benefits fraud in Canada occurs daily and costs the system hundreds of millions of dollars annually. Equally unfortunate is how misunderstood it is.

As part of the Canadian life- and health-insurance industry’s anti-fraud awareness campaign Fraud=Fraud (fraudisfraud.ca), a survey commissioned by Environics Research revealed that 75 per cent of Canadians incorrectly believe that the only punishment for benefits fraud is having to pay higher premiums or being forced to reimburse claim payments.

But whether you’re the ringleader, an opportunistic partaker or even an unknowing participant, health- and dental-benefits fraud is a real crime with real consequences. Let’s start with the personal consequences:

At the lightest level, when you or your co-workers commit benefits fraud, the insurance provider could increase premiums or your employer could reduce coverage to recoup losses. In addition to having to pay the money back, you could lose your benefits completely – devastating for many Canadians that require expensive prescription drugs, dental care or other health-care support through their benefit plan.

On a more severe level, you could lose your job. Stealing from your employer is a serious offence, and most workplaces have zero tolerance. Being fired for benefits fraud could also impact your chances of being employed in the future.

Finally, being convicted of fraud results in a criminal record. Jail is a possibility, but even if you avoid it, having a criminal record could make it very difficult for you to get a job or travel – potentially for the rest of your life.

Beyond the financial impact on the convicted employee, there’s the humiliation. Also, the fraudster’s innocent colleagues at work may find their benefits become more expensive, reduced or even eliminated.

Here are three ways that insured, working Canadians can protect their benefits and avoid becoming involved:

• First, learn how to detect the signs of fraud. Benefits fraud is not always easy to spot, especially when a trusted co-worker, friend, family member, or health or dental service provider suggests it. Warning signs include feeling pressured by your service provider to get unnecessary products or procedures or being encouraged by a colleague to visit a service provider offering cash or other incentives in exchange for your policy information.
• Second, simply refuse to participate. The adage “if it seems too good to be true it probably is” applies here. Start by familiarizing yourself with your benefits plan and the limits of your coverage, don’t lend your card to anyone, and be sure you understand the treatments, services and products being prescribed to you. When in doubt, push pause and ask your human resources department or benefits provider if what is being offered to you is allowed.
• Third, report it. While benefits fraud is easy to view as a faceless, victimless crime, it affects everyone – including your employer, your colleagues and your family. If you suspect that a co-worker or health or dental service provider is committing benefits fraud, you can report it anonymously by visiting the fraudisfraud.ca website.

The insurance industry is working hard to reduce fraud through investments in personnel and technology that detect and investigate fraud, by working with employers to educate employees, and through a large, bilingual public awareness campaign that provides information on how to recognize, reject and report fraud. But to effectively eliminate this costly problem, working Canadians need to take a stand and protect the vital benefits coverage they work so hard to earn.