After Moneylife exposed fraudulent mis-selling of insurance policies by AB Capital, a corporate agent of Reliance Life, the regulator and the insurer has taken some corrective action. Reliance Life admits to receiving 2,141 complaints till August 2013, and has terminated AB Capital, launched criminal proceedings and so far got arrested five salesmen. But we keep receiving complaints
One of the biggest examples of systematic, fraudulent mis-selling of insurance policies, that has only led to a regulatory rap on the knuckles is that of AB Capital, a corporate agent of Reliance Life insurance, which has sold insurance policies to thousands of persons across the country on the fake assurance that they will get an interest free (or very low interest) loan that is equal to 10 times the premium paid.
Moneylife began to take up these cases in the early part of 2013 and wrote to the Insurance Regulatory Development Authority (IRDA) for the first time in July 2013. We have received complaints from all over India from people who did an internet search to figure out how to redress grievances. Some of these had even borrowed money to pay the premium in order to obtain the interest free loan. While some of those, who were duped, are not financial savvy, many included software engineers from leading companies. Clearly the fraudsters had a sophisticated technique of convincing people.
Thanks to the regulator’s pressure, 95% of the complaints forwarded by Moneylife Foundation to Reliance Life have received refunds. However, the flood of complaints shows no sign of stopping. We were convinced that complaints which came to us are just a drop in the ocean. Queries to IRDA, about this rampant cheating in July 2013 and January 2014 elicited no response, forcing us to file a Right to Information (RTI) application at the end of January.
Following a first appeal, we received a detailed response with some stunning revelations.
First, while IRDA did not respond to us, it had been pushing Reliance Life to redress grievances. Secondly, Reliance Life told IRDA that until 22 August 2013 it had received 2,141 complaints against its corporate agent AB Capital. These are a vast multiple of those who approached Moneylife Foundation and had their complaints redressed. It is not clear whether all 2,141 cases have been redressed by Reliance Life.
Thirdly, Reliance Life told IRDA, “AB Capital has already terminated those employees, who indulged in mis-selling and has also lodged criminal complaints (NC) against such employees. Five salesmen have been arrested so far. Considering, the large number of complaints received against the corporate agent, the company terminated the agreement with AB Capital on 8th July.” Moneylife Foundation started taking AB Capital complaints to Reliance Life in June 2013.
Fourthly, Reliance Life has told IRDA that there are no more complaints pending about AB Capital. However, this is clearly incorrect, since Moneylife Foundation continues to receive fresh complaints even today. So far, Reliance Life has paid over Rs22 lakh to 31 people duped by AB Capital based on complaints sent by Moneylife Foundation. The amounts range from Rs30,000 to Rs2 lakh each.
In fact, while IRDA has not obtained all the details of the total extent of mis-selling by Reliance Life’s agent, or the correct data on redress, it has also not initiated any action against the company. On the contrary, Reliance Life seems to be comfortable enough to demand greater proof from victims of mis-selling. In a few recent cases, it only redressed complaints from those who had taken the precaution of making voice recordings of the telecallers and were able to provide proof.
This is clearly an issue on which the insurance regulator also needs to be held accountable for dragging its feet over the massive fraudulent actions by insurance agents. So far IRDA has done nothing beyond sending letters and asking for data and information. Were the regulator been more pro-active or the Finance ministry and the Ministry of Consumer Affairs more diligent in their supervision, we would have seen some attempt to make companies more accountable for fraud and mis-selling by their agents.
But this is clearly another long battle along with better financial literacy among those who buy insurance.
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A software that will tell you what kind of ailment you will have, based on your DNA! Is it scientific?
“Every man’s life lies within the present; for the past is spent and done with, and the future is uncertain.” — Marcus Aurelius
A few days ago, The Hindu reported on a medical horoscope available in a new software that is expected to be installed soon in all major hospitals. One has only to answer some questions and the software will predict your medical future accurately. This is not new. “Doctors have been predicting the unpredictable future of their patients all the time” felt WJ Firth, professor of physics at Strathclyde University in Glasgow, in the British Medical Journal in 1991.
Following similar advice, Angelina Jolie had her beautiful breasts removed, a couple of months ago, to avoid any future chance of her getting breast cancer based on her genetic data. Ultimately, science claims to have triumphed over nature in unravelling the secrets of the future against the natural law.
Why does nature intend to keep your future a secret? That is the only way a human being can be happy on this planet. Ignorance is bliss here. Imagine, for a minute, that the software declares that you will get cancer in the near future. Your life, from that time onwards, will be totally different and, for all you know, you might die of sheer fear of cancer.
When it comes to our poor village astrologer predicting people’s future, based on their horoscope, the rationalist ‘scientific’ community demonises him, in no uncertain terms. But we prefer a predictive software because it represents technological sophistication. The software is supposed to predict the future based on your genetic make-up, like the one Angelina Jolie experienced.
Curiously, not all the DNA in your chromosomes come from your evolutionary ancestors. Your DNA includes the genes from at least eight retroviruses and many other germ genes. At some point in human history, these genes were incorporated into human DNA. These perform important functions; yet, they are entirely alien to our genetic ancestry. There are more than 10 times the germ genes in your metagenome so that there is more bacterial life inside you than ‘human life’!
The software astrology is based on our genetic make-up as we are taught to believe that genes determine what each of us is like, physically; but genes are only a tiny part of our DNA! A large portion (97%) of our genes was thought to be junk, until now. We now realise that the process that goes on outside the genes—epigenetics—has a major role to play in our evolution and development. Otherwise, how can just 23,000 genes represent all that happens to us? The so-called junk (epigenetics) is as important as, if not more than, the known human genes.
The picture of the world we ‘see’ is also artificial. Our brains don’t produce an image the way a video camera works. Instead, the brain constructs a model of the world from the information provided by modules that measure light and shade, edges, curvature and so on. This also compensates for the rapid jerky movement of our eyes, the saccades. We have more than just five senses.
With all these new data accumulating from the new wisdom of quantum mechanics, the old idea of predicting the future from our genetic make-up, as they did in the case of Angelina Jolie, looks childish, to say the least. What worries me is that the new software astrology might do far more damage than poor village astrologers that rationalists cry hoarse about. I might now repeat my usual warning to the apparently healthy in society. Do not go to the hospital when you are healthy. You might get a wrong prediction of your future, thanks to the new software toy. Do see your doctor for any deviation in your health without fail and be an intelligent partner in your treatment process.
“In times of change, learners inherit the Earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists.”— Eric Hoffer
Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS.
A ProPublica analysis of recently released data shows that dozens of physicians who received payments from Medicare in 2012 had been kicked out of Medicaid, charged with fraud, or settled claims of overbilling Medicare itself.
This story was co-published with NPR
In August 2011, federal agents swept across the Detroit area, arresting doctors, pharmacists and other health professionals accused of running a massive scheme to defraud Medicare.
The following month, several of those arrested —including psychiatrist Mark Greenbain and podiatrist Anmy Tran — were suspended from billing the state's Medicaid program for the poor.
"Health care fraud steals funds from programs designed to benefit patients, and we all pay for it," U.S. Attorney Barbara McQuade said in a press release at the time of the arrests. "We hope that the strength of our efforts will have a deterrent effect."
But the indictment and Medicaid suspensions didn't deter Medicare from continuing to allow the doctors to treat elderly and disabled patients — and billing taxpayers for their services.
In 2012, Medicare paid Greenbain more than $862,000, according to newly released data on Medicare payments to physicians. Tran received $155,000.
Greenbain and Tran were among dozens of doctors identified by ProPublica who Medicare kept paying after they were suspended or terminated from state Medicaid programs, indicted or charged with fraud, or had settled civil allegations of submitting false claims to Medicare.
Outlays to these doctors amounted to more than $6 million in 2012, ProPublica's analysis shows. That's a small fraction of the $77 billion Medicare has publicly reported paying that year for doctors' visits and outpatient services in its Part B program, but it signifies a hole in regulators' ability to protect the program — and patients — against fraud and abuse, said current and former government officials and fraud experts.
The total dollars paid to sanctioned doctors is likely much higher. Only a handful of states post online the names of doctors terminated from Medicaid programs in a way that can be accurately matched to Medicare Part B payments.
"If you've been suspended or terminated in one of the federal programs...I would think that you'd be suspended in the other programs, just as a basis of good practice," said Louis Saccoccio, chief executive of the National Health Care Anti-Fraud Association.
Part B payments to doctors were released last week for the first time. A court injunction that had kept the information secret for 35 years was lifted last year as a result of a lawsuit by Dow Jones & Co., parent company of the Wall Street Journal.
But Medicare has long had access to the information. "They're the ones doing the paying," Saccoccio said.
Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, said he could not discuss the status of individuals, such as Greenbain and Tran, both of whom were finally barred from billing Medicare this month.
Albright said the Medicare payment data may not reflect money already recovered by his agency or held back from providers suspended from billing the program.
Preventing improper payments is a top priority for CMS, Albright said. The agency has employed new enrollment screening techniques to prevent high-risk providers from getting into the system and is using advanced data analytics to spot fraudulent billing before payments are made, he said. "Already, we have cracked down on tens of thousands health care providers suspected of Medicare fraud," he said in an email.
Medicare's fraud-fighting efforts have been criticized repeatedly in recent years. In an audit released last month, the inspector general of the U.S. Department of Health and Human Services found that about one-third of states hadn't told CMS when they terminated providers from Medicaid and others had provided incomplete information, hobbling regulators' ability to flag sanctioned professionals.
In December, the inspector general faulted Medicare for not systematically reviewing the billings of the program's top-paid doctors and said it should be doing more to spot aberrant claims.
Last year, ProPublica reported that doctors who had been terminated from Medicaid or had been disciplined by state medical boards were able to continue prescribing medications to beneficiaries in Medicare's drug program, prompting Sen. Charles Grassley (R-Iowa) to push for better coordination.
Medicare has more direct responsibility for overseeing activities in Part B than in the drug program, which is administered by private insurers. The drug program doesn't even require that prescribers be enrolled in Medicare and payments go to pharmacies, not doctors. By contrast, in Part B, it's up to Medicare to monitor services and payments, which go to clinicians or their employers.
"There's been a disconnect between Medicaid and Medicare on problem providers," wrote Grassley, ranking Republican on the Senate Judiciary Committee, in an email to ProPublica. "The release of Medicare billing data should help force better communication between Medicaid and Medicare on these providers. The new transparency makes it harder to ignore when doctors who harm patients or defraud taxpayers in one program face no consequences in the other program."
Sen. Tom Carper, (D-Del.), chair of the Senate Homeland Security and Governmental Affairs Committee, credited Medicare with ramping up efforts to verify the credentials of those treating its beneficiaries. "But there is still much work to be done," he said in a statement.
Among the physicians ProPublica found who continued to collect Medicare payments after being flagged by law enforcement or other oversight agencies:
Dr. Lawrence Eppelbaum, a Roswell, Ga., pain doctor convicted last year of inducing patients to be treated at his Atlanta pain clinic by paying their travel fees through a purported charity he controlled. He was indicted on the charges in March 2011, but Medicare paid him $500,000 to treat 80 patients the following year. This February, Eppelbaum was sentenced to 50 months in prison and fined $3.5 million. He is appealing.
In a sentencing memorandum, Eppelbaum's lawyer maintained that Medicare did not lose any money because of the doctor's conduct. "Virtually every patient would have received treatment somewhere, by some doctor," he wrote. "Thus, Medicare would have paid the exact same amount of money, albeit possibly to another provider."
Michigan ophthalmologist Matthew Burman was suspended by the state's Medicaid program in 2009 after he was convicted of a misdemeanor count of criminal sexual conduct arising from a patient's accusation against him. He subsequently surrendered his medical licenses in Texas and California and agreed not to activate his registration in New York. He was paid $379,000 by Medicare in 2012. (Medicare has not released payment data for prior years.)
Burman, who continues to practice in Michigan, said he could have re-enrolled in Medicaid but chose not to. "One has nothing to do with the other," he said. "I didn't violate any Medicare rules. Medicare has nothing to do with why I'm not a Medicaid provider."
Las Vegas pain doctor Steven Kozmary agreed in December 2011 to pay the federal government $1 million to settle health care fraud allegations involving Medicare and other programs. The government could have moved to terminate him from Medicare, according to the settlement. Instead, in 2012, Medicare paid him $563,000. He was disciplined by Nevada's medical board in 2013 related to the 2011 settlement. He did not return a phone call.
Louisville Dr. Steven Stern and his practice paid $350,000 to settle allegations of overbilling Medicare in September 2011. He and his practice were accused of overbilling Medicare for infusing Infliximab, a drug used to treat rheumatoid arthritis. Specifically, they were accused of splitting vials of the drug across multiple patients but billing as if a whole vial was used for each. In 2012, Stern received more than $3 million in payments from Medicare, including $2 million for infusing Infliximab. He did not return a phone call seeking comment.
Eight of 14 New Jersey health providers arrested in December 2011 on charges of receiving kickbacks for referring Medicare and Medicaid patients to a specific MRI center continued to be paid by Medicare in 2012. At the time of the arrests, Tom O'Donnell, special agent in charge for the HHS inspector general said, "The audacity of these physicians should offend honest taxpayers, especially at a time when our taxpayer resources are stretched thin."
Even a guilty plea sometimes wasn't enough for Medicare to cut off payments. Dr. Anthony Jase of New Orleans pleaded guilty to two counts of health care fraud in October 2011. He still collected $97,460 for Medicare billings in 2012. Last fall, he was sentenced to 15 months in prison and ordered to pay $360,293 in restitution.
"It certainly looks like there is a need for more attention," said Mark McClellan, former administrator at CMS who is now at the Brookings Institution. "One important consequence of the release of this information at the physician level is that it will lead to some further analysis and actions against these truly outlier physicians who are clearly billing improperly."
ProPublica's analysis also found payments to doctors who were subsequently barred from billing the program by the HHS inspector general, mostly because of fraud convictions. Medicare paid 135 of them more than $18 million in 2012, before they were kicked out.
Some doctors have been indicted post-2012, including Michigan oncologist Farid Fata, a Michigan oncologist who was paid $10 million in 2012, ranking him among Medicare's top-paid providers that year. Last year, Fata was accused of misdiagnosing patients with cancer so he could give them unnecessary, expensive treatments. Fata has pleaded not guilty; his lawyer did not respond to a request for comment.
In a conference call last week with reporters, CMS' principal deputy administrator Jonathan Blum said the agency knows it can do more to find fraud. "We know that there's waste in the system. We know that there's fraud in the system. We want the public's help" to review the physician payment data and report suspected wrongdoing.