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Case Studies

The Malawi tale of investigation: A Mediclaim, that never was

3rd Nov, 2015

Disclaimer: The narrated article / case study is based on true incidents / happenings and the details of the investigation conducted are absolutely true and real. However, for the sake of protection of privacy and client confidentiality, the names of subjects and entities / establishments have been changed but the locations are real and accurate.

The present incident brings one such tale to light where the Insured Claimant Mr. Godfrey Mandwe, a executive working and living in London, UK, hatched a well planned conspiracy of raising a bogus and fake claim on the basis of forged medical diagnosis and subsequent treatment including hospitalization. The Insured claimant raised a claim of nearly 5000 GBP (Five thousand British Pounds), on pretext of reimbursement of medical expenses including those of hospitalization, diagnostics, treatment process, nursing and care. The Claimant Mr. Mandwe, submitted a trail of documents including reports of diagnostic tests, X-Ray images, hospitalization bills, Doctor’s prescriptions, discharge summary and post discharge medication bills and Physician’s fitness certificate. All looked very genuine and the Insurance Company, at the outset, had no reason to disbelieve the Insured’s claim and deny the reimbursement. The Insured had cleverly chosen a remote location in a small country so that the UK based Insurance company could be easily dodged. All looked well at the Claims processing department of this UK based Insurance Company, which was busy processing the claim of Mr. Mandwe, till one of their officers realized a slight disconnect in the sequence of events, based upon which the Insurance company decided to verify the authenticity of the claims and they decided to go in for an on-site Insurance claim verification and investigation in Africa and that is where Greves Group came in.

Owing to the remote location and the challenges of an unexplored destination, the herculean task before the Insurance company was to identify an effective Insurance Claim Investigator or an Insurance Claim verification company capable of rendering effective and accurate Insurance Claim verification service in such a remote location of Africa and after due consideration, the task was assigned to Greves Group.

So, the investigation started and the investigator, under authorization from the UK based Insurance company, initiated the on-site investigation by first visiting the hospital in question. The hospital called National Public Development Medical Centre (NPD) is a part of a registered Non Government Organization of Malawi. At the outset, the investigator made preliminary inquiries in the vicinity under discreet pretext and was taken aback to know that the said NPD Medical centre is just a primary medical care centre, much like a dispensary and does not qualify to be called a hospital. The investigator further gathered intelligence only to get confronted with deeper truth and facts that the said NPD medical centre is just a day care and nursing facility and does not even have an in-patient block and the very question of admitting any patients or having any hospital like treatment set-up, does not arise. Upon visiting the NPD facility, the investigator could only see a set of four to five rooms built within the premises of a local mosque where a sole doctor named Dr. C. Tikolo, was seen attending some walk-in patients, who had come there for routine medication. Dr. Tikolo remained nervous throughout the interview with the Insurance Claim Investigator and the discomfort became clearly visible on his face. In order to get rid of the investigator’s uncomforting questions, Dr. Tikolo diverted him towards the Administrator of the NPD Medical Centre who worked from the Administrative Office located a few yards away and the investigator was quietly escorted to the Administrator Mr. Muhammed. Mr. Muhammad received the investigator with a friendly warmth and without wasting any time, he extended a generous offer of a mouth watering kick-back to the investigator, hoping well that the investigator could be easily lured into this trap of material inducement. Unfortunately for Mr. Muhammed, things did not go the way he wanted them to go, and the investigator, living up to the ethics and professional standards of Greves Group, bluntly turned down the offer for inducements and insisted on inspecting the office copies of the Hospital records and supporting documents filed by the Insured claimant. After three days of regular follow-up and after extending the threat of initiating a Police action against the NPD medical Centre, Dr. Tikolo and Mr. Muhammed, Mr. Muhammed finally broke down and confessed to forgery and to his being a partner in crime. He also confessed to the role of all others including Dr. Tikolo himself and some other support staff. Upon sustained enquiry, Mr. Muhammad shared the original office copies of the out-patient consultation slips issued to the Insured claimant Mr. Mandwe and then went on to narrate that Mr. Mandwe and Dr. Tikolo are the real culprits. He went on to state that Mr. Mandwe and Dr. Tikolo are childhood friends and while Mr. Mandwe emigrated to UK and picked up a job there, Dr. Tikolo pursued medicine in his home country and went on to become a qualified doctor. Lately when the duo met, they collectively hatched the conspiracy of committing this Insurance fraud by having this bogus Insurance claim processed and what lured the duo most is that the UK based Insurance Policy, which shall pay them close to 5000 GBP (Five Thousand British Pounds).

After having realized that he has gathered sufficient intelligence to interpret that the claim in question is bogus and fake, our experienced investigator took no time to realize that he needs to have some concrete and written evidence to take this forgery on record so that not only the claim in question can be rightfully denied but appropriate criminal action can also be taken against the claimant for forgery and cheating so as to create a deterrent in the society. The investigator, acting with utmost wisdom and active state of mind, took Mr. Muhammed to task and in a controlled manner, intimidated him with the threat of a Police action against him unless he co-operates with the investigation and helps in exposing the real culprits, to which Mr. Muhammed readily agreed and the very next morning, he handed over office copies of the original documents along with a letter of apology for and on behalf of the NPD claiming that the NPD medical centre has not issued any of the documents in question and that the NPD medical centre is only a day care and primary medical care unit and it does not have any hospital like infrastructure and does not admit patients. The letter also stated that there is no radiology lab, X-Ray unit or diagnostic centre in the NPD medical centre and the documents and reports attached by the claimant are fake, forged and bogus.

After having collected all these documents, the investigator tendered his detailed findings along with the original letter of apology issued by Mr. Muhammed for and on behalf of the NPD medical centre and the Insurance company back in the UK, not only rejected the fake insurance claim filed by Mr. Mandwe, but also black-listed him as a customer disabling him from buying Medical or Life Insurance Policies form any Insurer in the UK and simultaneously initiated Criminal proceedings against Mr. Mandwe. The investigation concluded with great recognition and applaud for the Greves Group and its on-ground affiliates, partners and network associates and certainly decorated another feather in the cap of Greves Group of investigation companies.