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Can you recognize benefits fraud?

Benefits fraud is not always easy to spot, especially when a trusted coworker, friend, family member or service provider suggests it.

Benefits fraud occurs when you intentionally submit false or misleading information to your insurance provider for financial or personal gain.

Who commits health and dental benefits fraud?

Benefits fraud can be committed by health or dental service providers, plan members or both.

Most people use the benefits they are entitled to, when and if they need them. When other people commit benefits fraud, it’s not stealing from the insurance company; it is stealing from your plan and putting your benefits and all that your plan provides you at risk.

Depending on your group benefits plan, some portion of the benefit costs may be paid by you and/or by your Employee Life and Health Trust (ELHT).

Safeguarding your benefits will help to keep your benefits affordable, accessible and sustainable for many years to come.

What is health and dental benefits fraud?
Recognize the warning signs

Learning how to recognize benefits fraud is the first step toward preventing it. Look for these warning signs:

  • Feeling pressured by your health or dental service provider to get unnecessary products or procedures

  • Being encouraged to claim products or services, that are not eligible as a benefit under your plan, as different products or services that are eligible

  • Health or dental service providers who seem more concerned with the details of your insurance coverage than providing the right product or service

  • Feeling encouraged to include incorrect or misleading information on a claim

  • Being asked to sign a blank claim form (often completed later with misleading information)

  • Health or dental service providers who use your plan membership information to charge for products and services you never received

  • Being offered cash or other incentives in exchange for your policy information

If you suspect you are being encouraged to submit a fraudulent claim, or something just doesn’t feel right, report it to your ELHT or insurance provider immediately.

Join the conversation on Twitter and Facebook using #SafeguardYourBenefits.

Source: Canadian Life and Health Insurance Association (CHLIA)

Do you suspect fraud?
If you wish to report suspected fraud, please use the telephone number or links below to provide a tip directly to the individual insurer.
For members of the Employee Life and Health Trusts (ELHT) and OTIP:
For members of the CUPE Education Workers’ Benefits Trust only:
Canada Life

Related links:
Safeguarding your benefits with the three Rs
Refuse benefits fraud to protect your benefits 
Reporting benefits fraud

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