With an understanding of what group benefits fraud looks like, you can help stop benefits fraud. By learning how to recognize the warning signs of benefits fraud, you can refuse and report it.

How to recognize benefits fraud

Benefits fraud is not necessarily easy to detect, especially when it is presented to you by your friend, a family member, or a trusted peer at work. Here are some warning signs to be aware of and report to your insurance company if you recognize them happening around you:

  • You are pressured and encouraged by your health or dental care provider to purchase products or services that are unnecessary or unwarranted such as additional braces, shoes or stockings, or higher end restorative dental treatment such as implants
  • Being enticed to submit receipts for products or services that are not eligible under your benefit plan (such as handbags, fashion shoes or cell phones) as eligible products or services (such as physiotherapy treatment, compression hose or tens machines)
  • Be on the look-out for service providers who ask a lot of questions and seem to care more about the details of your insurance coverage than the actual reasons you want their products/services
  • Being made to feel its ok to include incorrect or misleading information within your claims submission, such as dates of service other than the date the service took place, or increasing the cost of the product on the receipt to allow for increased reimbursement
  • Providers who request you sign a blank claim form to be left in your clinic file. These blank forms are often completed later with misleading information and submitted to your insurance company without your knowledge or approval
  • Seeing claims or payments from your insurance company that you do not recognize – Often a sign of health or dental service providers using your plan membership information to charge for products and services you never received
  • Service providers requesting the details of your policy including your individual policy and certificate number to be held on file and/or being offered money, gift cards, non-medical products or services or other incentives in exchange for this information
  • Service providers who ask for your login information or access to your benefits plan web account. You should always keep that information private. It is never needed by a service provider.

Still not sure what constitutes benefits fraud? Test yourself with this quiz.

How to report benefits fraud

Group benefits fraud affects everyone, and it’s our shared responsibility to report it when we see it. If you suspect that a co-worker or health or dental service provider is committing benefits fraud, you can report it to Equitable Life’s Special Investigations Unit by email at: siu@equitable.ca or through our tip line at: 1.800.265.8899. 

You can also report fraud anonymously to the larger insurance industry.