By Riyaz Lakhani
In Dr. Birbal

The Hospital Conspiracy Unveiled: A Tale of Insurance Fraud and Medical Malpractice

Dr. Birbal, a seasoned insurance investigator, was conducting a routine review of insurance claims when he came across two cases from KFP Hospital. Both cases raised suspicion due to the similarity of their symptoms and the fact that both patients were single-insured with no prior claims history.
The first case was of Kunal Band, a 23-year-old male who had been suffering from fever, body pain, and joint pain for 2-4 days. He had taken dolo tablets on his own but had no relief. He had a rash on his back that disappeared after hospitalization. He had a history of traveling to Tirupathi Balaji 15 days before the onset of symptoms. He was admitted to the hospital on 27.02.23 in the afternoon and had undergone X-ray chest and daily blood tests. The patient had been prescribed InjPan, Inj Tazact, and IV fluids, and was in a single private room with AC and TV. On questioning, his brother revealed that the patient worked at Chandrakant Saloon at Bhaji Mandai. Dr. Birbal found several discrepancies in the case, including the fact that the patient seemed unfamiliar with his medical history and the date of admission had been struck out on the claim form. The lab reports also seemed manipulated, and the patient was negative towards the hospital. Dr. Birbal recommended that the claim be rejected.

The second case was of Rohit Waghmare, a 27-year-old male who had complained of fever, joint pain, throat pain, cough, and a rash on his body. He was admitted to the hospital by a friend on 26.02.23 at 3 PM, after having consulted at the hospital at 11 AM. He had a history of jaundice, for which he was admitted to the same hospital one and a half years ago. He was investigated with CBC and daily blood tests and was in a twin wardroom. He had not gone outside the hospital for any investigation, and no one had accompanied him at the time of the virtual call. He worked at Amanora Mall in Pune and had traveled to Daund for admission. Dr. Birbal found several discrepancies in this case as well, including the fact that the admission timings were different as per the patient’s statement and the admission sheet provided. The lab reports were also suspicious, and there was no evidence of any bedside medicines. Dr. Birbal recommended that the claim be rejected.

Dr. Birbal, using the telemedicine tool called Remolin, reviewed both cases personally and found a striking similarity between the two cases. Both patients had similar symptoms, had been admitted to the same hospital, and had received inadequate investigations and treatment. The fact that one of the patients had traveled 100 km to this hospital was also suspicious. Dr. Birbal connected the dots and requested the insurance company to de-panel the hospital due to the suspicious activities observed. He noted that any claim admitted to this hospital should be directly rejected. Dr. Birbal’s investigation prowess and intelligence helped the insurance company save a significant amount of money and prevent fraud.

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