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Benefits fraud

Overview

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What is fraud?

Have you ever been tempted to purchase non-prescription sunglasses and claim them on your plan as prescription eyewear? Or maybe you’ve thought about claiming your visit to the dentist under your spouse’s name since you already hit your dental maximum for the year. These aren’t innocent mistakes—they’re examples of benefits fraud and abuse, and they have serious impacts.

Benefits fraud happens when a person or group deliberately deceives the claims process for financial or personal gain. This can mean submitting a false claim, forging receipts, sharing benefits with others or misrepresenting services.

Committing benefits fraud costs more than just high premiums—it may result in a criminal record.

Committing benefits fraud costs more than just high premiums – it may result in a criminal record.

Impacts

Increased premiums

Benefits fraud and abuse cost the Canadian health insurance industry. This leads to increased costs that are passed on to employers and ultimately to employees or customers.

Inability to get insurance

Benefits fraud and abuse could lead to the creation of inaccurate or false records, which could affect a plan member’s ability to be insured through Alberta Blue Cross® or another benefits provider.

Reduction of benefits

When employers can no longer afford the additional costs brought on by benefits fraud and abuse, this results in the reduction or elimination of benefit plans.

Consequences

Court—resulting in a criminal record.

Loss of employment.

Loss of benefits—repayment of false claims.

Many people think benefits fraud is a minor offence and believe the biggest consequence of committing benefits fraud or abuse is having to reimburse the false claim payments or to pay a higher premium.

In reality, the consequences are much more severe. You could lose your benefits completely, lose your job and may result in a criminal record.