When it comes to fraud, group benefits fraud is likely not even on your radar. Fraud scams including credit card and pyramid schemes, auto and life insurance fraud, internet sales fraud and identity theft make the news and have a direct impact on individuals, so they’re top of mind instead.

Which begs the question, why does benefits fraud matter? Surely a few rogue claims won’t hurt your employer or impact the premiums you pay. 

It isn’t just a few small claims

Group benefits fraud is much more than a few people passing off fashion sunglasses as prescription eyewear. You would be surprised at the size and sophistication of fraud schemes and the impact they can have on group benefits plans. Receipt selling, kickbacks and identity theft are all concerns.

 Along with this growing criminal activity, the rising costs and need for health care means that each fraudulent claim has a bigger financial impact. Law enforcement agencies are concerned about this trend, but they have limited resources and need support from insurers, employers and plan members to stop it.

How fraudulent claims impact you

Your employer has made an investment in your group benefits plan, paying premiums and providing group benefits to keep you and your family happy and healthy. Together with the insurer, your employer has designed a plan that provides as much benefit as possible, while keeping costs sustainable so that they can keep offering this support for the foreseeable future.

If the insurer ends up paying for too many fraudulent claims, premiums may increase to cover these costs and your employer may no longer be able to afford their group benefits plan. This could leave you without the support and protection you count on. Those who commit benefits fraud are endangering the benefits plans and wellbeing of all plan members.

But it goes beyond just your health benefits. Employers generally establish a budget to cover the total compensation package for employees. This would include salaries, health and dental benefits and retirement savings contributions. If the cost of the health and dental benefits increases due to paying fraudulent claims, there may be increased strain on the resources available to support the rest of the compensation package. Employers may have tough decisions to make.

Our focus on fraud

At Equitable Life, we’re tackling these challenges by making significant investments in fraud investigation and risk management including:

1: Knowledgeable, experienced staff

Our team of investigators scour our claims data and use their experience to identify red flags that can indicate fraud. They then investigate, even going undercover, to discover the truth.

2: The use of Artificial Intelligence tools

The core benefit of Artificial Intelligence (AI) software is its ability to process data and learn from the patterns, drawing smart conclusions. We use AI tools to wade through our reams of data and help direct investigators to suspicious patterns of activity.

3: Zero tolerance for fraud

Together with the Canadian Life and Health Insurance Association (CLHIA), Equitable Life is committed to helping everyone recognize, report and reject fraud. Our zero-tolerance policy supports our commitment to protect the plan members who trust and rely on us.

Benefits fraud affects everyone, and it’s our shared responsibility to report it when we see it. If you suspect that a co-worker or health or dental service provider is committing benefits fraud, you can report it to Equitable Life’s Fraud Investigations and Risk Management team by email at: investigations@equitable.ca or through our tip line at: 1.800.265.8899.  You can also report it anonymously to the broader insurance industry.