Fraud and abuse causing Rs 8000 cr to Rs 10000 crore loss to health insurance: BCG

MUMBAI: Fraud and waste remain a costly drag on the health-insurance system with Rs 8,000–10,000 crore of leakages in claim payouts leak each year according to a report by Boston Consulting Group and Medi Assist.
The report says that fraud and unnecessary claims push up insurance premiums, hurt insurers’ finances and waste public money. It also points out that poor data systems and weak checks mean patients often end up paying more from their own pockets.
To fix this, the report suggests a stronger, coordinated approach. It calls for better ways to prevent and detect fraud, clear national rules for medical coding, smarter use of artificial intelligence and faster sharing of data through the Ayushman Bharat Digital Mission and the National Health Claim Exchange so hospitals and insurers can work together more smoothly.
Medi Assist, a health-benefits administrator listed on the NSE and BSE, believes technology will do much of the heavy lifting. It has rolled out an AI stack spanning MAven Guard, a real-time fraud-detection engine, and MAgnum, a system designed to make hospital cashless processing smooth. The firm says progress is already visible: 15% of members now leave hospital before a final bill is raised—some 400,000 discharges—while a quarter of its network of more than 4,000 hospitals has shifted to next-generation workflows. Cashless claims account for 70% of claim value; 85% are filed digitally.
“As India’s health system stands at an inflection point, the next decade will be defined by connected data and intelligent automation,” said Satish Gidugu, Medi Assist’s chief executive. Reducing fraud and shoring up digital trust, he added, will help keep care “accessible, affordable, and accountable for all citizens.”
For Swayamjit Mishra of BCG, the real gains lie in curbing inefficiencies in the “remaining 8%” of claims that fall between harmless and outright fraudulent. Targeting that segment with better intelligence “can advance the government’s Insurance for All vision by nearly five years.”






Get an chance to win ₹5000 Amazon Voucher by taking part in India's Biggest Habit Index! Take the survey here