By Riyaz Lakhani
In Dr. Birbal

Dr. Birbal unearths misrepresentation of facts in this case.

It was a chilly winter morning on December 24th, 2022, when Shivananda set out on his motorcycle for his usual bakery and confectionary delivery from Sasthan to Bramhawar.

But fate had other plans. As Shivananda was crossing the road, a car came speeding out of nowhere and crashed into his motorcycle. Shivananda was thrown off the bike and onto the ground.

The driver of the car didn’t stop to check on Shivananda or call for help. They simply fled the scene, leaving Shivananda lying there in pain and shock.

Fortunately, another car came along and the driver saw what had happened. They pulled over and rushed to Shivananda’s aid, calling an ambulance and taking him to the nearest hospital.

When Shivananda’s brother-in-law received the call, he was terrified. He rushed to the hospital to find Shivananda lying in a bed, his face and body bruised and battered.

The doctors at Mahesh Hospital worked quickly to assess Shivananda’s injuries, which included a concussion, broken bones in his hands and knees, and cuts and bruises all over his face and body. They ordered a CT scan and X-rays to get a better understanding of the extent of his injuries.

Despite the pain and discomfort, Shivananda was in good spirits and eager to recover as quickly as possible. He knew he had an insurance policy that would cover the cost of his medical treatment, and he was confident that everything would be taken care of.

But little did Shivananda know, his troubles were far from over. That’s when Dr. Birbal was brought in to investigate. As a highly skilled and experienced doctor, Dr. Birbal was used to sifting through complex cases and getting to the bottom of things.

As he looked over the case, Dr. Birbal noticed a number of inconsistencies and red flags. For one, the Medical Legal Certificate (MLC) had not been completed, even though Shivananda had been involved in a serious traffic accident.

Furthermore, Shivananda’s driver’s license had lapsed and had not been renewed at the time of the accident. This raised questions about whether he was even legally allowed to be driving at the time.

Dr. Birbal also noticed that Shivananda’s brother-in-law had claimed that the accident had occurred in the morning, yet the hospital’s records indicated that Shivananda had been brought in at night. Another fact that was hidden was that Shivananda had been receiving treatment for both diabetes and high blood pressure for 5 years under the care of Dr. K. Shetty, which may have contributed to the accident.

And when the insurance company requested to check for PED (pre existing disease) for Asthma as part of their investigation, Shivananda’s brother-in-law denied that he had ever had asthma or used inhalers.

Given all of these discrepancies, Dr. Birbal determined that the there is blatant mis-representation of the facts and the case was likely fraudulent and recommended that the insurance company repudiate the claim.

In the end, Shivananda was left to pay for his medical treatment out of pocket, and he learned a valuable lesson about the importance of being honest and upfront when it comes to insurance claims.

QuicSolv’s “Dr. Birbal stories” are true accounts of fraud detection by experienced medical professionals over video using QuicSolv’s video conferencing solutions. The names in these stories have been changed to protect the identities of those involved. These stories are meant to serve only as a learning resource and light Sunday reading.

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