Schedule of Benefit for Medical Fees

Our business is conducted on the basis of good faith. We monitor claims using data mining and routinely audit claims by reference to medical records. We operate a policy of zero tolerance of fraud and misrepresentation. We consider the following to constitute fraudulent billing:

• Exaggeration of the complexity of the procedure performed - for example coding a diagnostic procedure as if it were therapeutic.
• Misrepresentation of the medical history or the procedure performed.
• Omission of material facts.
• The use of jargon or technical information which whilst strictly correct is presented in a way likely to mislead a non-medically qualified claims assessor (an example would be a claim for laser in situ keratomileusis (LASIK) coded as a keratoplasty).
• Unbundling.