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Contractual Changes for Improved Fraud Detection and Prevention

News Release

Industrial Alliance is committed to protecting plan administrators and plan members from increased costs due to fraudulent claims. In addition to ongoing measures that were previously communicated, contractual changes have been implemented to further reduce and prevent fraudulent activity.

A new exclusion was added to the Exclusions and Reductions section of the Supplemental Health Benefit to reflect the manner in which we have been managing our claims. This exclusion applies to all new group contracts, issued on or after July 1, 2012 and to all existing contracts as of December 1, 2012. The new exclusion is as follows:

EXCLUSIONS AND REDUCTIONS

The benefit does not cover any expense

y) For any care or treatment which was provided by a healthcare provider who, or a service provider that: 

i. has been charged with professional misconduct or improper practices; or 

ii. is under investigation by an official body resulting from a law or regulation; or 

iii. is under investigation by the insurer in regards to his professional conduct or practice; or 

iv. is a member of a profession that is not regulated by an officially recognized federal or provincial regulatory body in the jurisdiction where the services were provided and, in the reasonable opinion of the insurer, does not meet the industry standards relevant to his profession.

This contractual change was adopted to improve the ability of our investigative services team to efficiently deal with non-regulated providers that do not otherwise meet industry standards for their profession.

New paragraphs pertaining to fraudulent or misleading claims were also added to the Claims Notice section of the General Provisions. This change is effective immediately and applies to all new and existing group insurance contracts. The new paragraphs are as follows:

The insurer will undertake all necessary actions to detect and investigate fraudulent claims under
the group policy

It is a crime if a participant should knowingly, and with the intent to defraud the Insurer and the group plan, file a claim that contains any false, incomplete or misleading information.
The insurer retains the right to audit all claims at any stage, including after payment has been made, for fraud or misrepresentation. If the insurer determines that a participant has intentionally submitted a claim that contains false or misleading information, the insurer shall have the right, at its sole discretion, to notify the policyholder, decline the claim or require reimbursement, if the claim has been paid. In addition, the insurer will have the right to terminate the participant’s entire coverage under this policy including any coverage for the participant’s dependents, and will have the right to undertake the prosecution of the participant in accordance with provincial and/or federal law.

This addition will enable Industrial Alliance to request reimbursement for claims improperly paid as a result of fraudulent activity. Please keep this communiqué as an addendum to your contract until the latter is updated.

Communicating this information to plan members

Since the information contained in this communiqué pertains directly to your plan members’ coverages, we suggest that it be communicated to them promptly. We have prepared some suggested wording which you may use at your discretion to provide them with this information. It can be found on page 3 of this communiqué. If you received a paper version of this communiqué and want to obtain an electronic version of the Plan Member Communication, please contact our Client Service Department at 1 877 422-6487.

If you have any questions or concerns regarding this matter, please contact your benefits advisor or your Industrial Alliance group account executive.


PLAN MEMBER COMMUNICATION

Contractual Changes for Improved Fraud Detection and Prevention

We have been informed by Industrial Alliance that, in addition to ongoing measures, contractual changes have been implemented to further reduce and prevent fraudulent activity.

A new exclusion was added to the Exclusions and Reductions section of the Supplemental Health Benefit to reflect the manner in which we have been managing our claims. The exclusion is as follows:

EXCLUSIONS AND REDUCTIONS

The benefit does not cover any expense

y) For any care or treatment which was provided by a healthcare provider who, or a service provider that: 

i. has been charged with professional misconduct or improper practices; or 

ii. is under investigation by an official body resulting from a law or regulation; or 

iii. is under investigation by the insurer in regards to his professional conduct or practice; or 

iv. is a member of a profession that is not regulated by an officially recognized federal or provincial regulatory body in the jurisdiction where the services were provided and, in the reasonable opinion of the insurer, does not meet the industry standards relevant to his profession.

This contractual change was adopted to improve the ability of Industrial Alliance’s investigative services team to efficiently deal with non-regulated providers that do not otherwise meet industry standards for their profession.

New paragraphs pertaining to fraudulent or misleading claims were also added to the Claims Notice section of the General Provisions. The new paragraphs are as follows:

The insurer will undertake all necessary actions to detect and investigate fraudulent claims under
the group policy

It is a crime if a participant should knowingly, and with the intent to defraud the Insurer and the group plan, file a claim that contains any false, incomplete or misleading information.
The insurer retains the right to audit all claims at any stage, including after payment has been made, for fraud or misrepresentation. If the insurer determines that a participant has intentionally submitted a claim that contains false or misleading information, the insurer shall have the right, at its sole discretion, to notify the policyholder, decline the claim or require reimbursement, if the claim has been paid. In addition, the insurer will have the right to terminate the participant’s entire coverage under this policy including any coverage for the participant’s dependents, and will have the right to undertake the prosecution of the participant in accordance with provincial and/or federal law.

Please keep this communiqué with your booklet until such time you receive a new booklet.