Fraudulent Insurance Claims Through False Medical Records
Organized Crime Involving Dental Clinic and Counseling Director
Cases Where Counseling Director Is Also an Insurance Planner
Cases of patients undergoing dental-related surgeries such as implants being punished for insurance fraud are steadily emerging. Recently, there have been warnings to be cautious as organized dental insurance fraud involving collusion between agents and dental clinics has also occurred.
On the 31st, the Financial Supervisory Service issued a consumer alert of "caution" regarding common dental treatments such as implants and resin. As insurance claims related to dental insurance products increase, insurance fraud is also on the rise. Recently, it has developed into organized insurance fraud involving insurance agency (GA) agents and dental clinics, so caution is necessary.
The types of insurance fraud were diverse. A recruitment organization affiliated with Insurance Company A appointed B and C, who were consultation managers working at a dental clinic, as insurance agents. They conspired to actively encourage visiting patients to subscribe to dental insurance. They induced 10 patients who already had dental diseases to join insurance by pretending they had no prior treatment, then assisted in receiving treatment and embezzling insurance money amounting to 13 million KRW. Their fines were only 1 million KRW each.
Insurance agents and dental clinics also systematically inflated the number of treated teeth. They fraudulently issued patients' medical records and embezzled 970 million KRW in insurance money. Two dental clinic staff, six agents, and 28 patients involved in this case were referred to the prosecution.
There were also cases of inflating implant surgery records. Patient C received a false diagnosis certificate from D Dental Clinic stating "alveolar bone graft performed after tooth extraction" despite only undergoing implants without alveolar bone graft surgery. Using this method, C received 12 insurance payments totaling 12 million KRW. The director and consultation manager of D Dental Clinic assisted 27 patients, including C, in embezzling 113.59 million KRW over 102 instances using the same method. The director of D Dental Clinic was sentenced to 1 year in prison with a 2-year probation, and the consultation manager and patient C were fined between 4 to 5 million KRW.
There were also cases where actual surgeries were performed, but the surgery dates were split to overcharge. Four patients, including E, underwent implant surgeries with alveolar bone grafts on more than two teeth on a specific day, but received false diagnosis certificates from F Dental Clinic stating the alveolar bone graft surgeries were performed over multiple days. Through this, they received 21 million KRW in insurance payments over 12 instances. Patient E was sentenced to 6 months in prison with a 2-year probation, the director received 1 year in prison with a 2-year probation, and the consultation manager was sentenced to 8 months in prison with a 2-year probation.
A Financial Supervisory Service official stated, "The moment insurance money is received based on documents that differ from actual medical treatment, one becomes involved as an insurance fraudster and must return the fraudulently obtained insurance money as well as face criminal penalties," and emphasized, "We urge people to actively report to the Financial Supervisory Service if they are proposed insurance fraud or notice suspicious signs of insurance fraud."
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