Medi Assist, BCG flag ₹8,000–10,000 crore annual leakage in health insurance from fraud, waste and abuse

Medi Assist Healthcare Services and Boston Consulting Group (BCG) have highlighted a significant challenge in India’s health insurance ecosystem—an estimated ₹8,000–10,000 crore in annual claim payouts lost to Fraud, Waste, and Abuse (FWA).

The finding, published in a new joint report titled “From Suspicion to Solution: A Strategic Approach to Health Insurance Fraud,” stresses how data gaps, weak controls, and misaligned incentives are driving systemic leakages across the sector.

The report warns that FWA not only inflates premiums but also erodes insurer margins and places additional pressure on public resources.

According to the analysis, around 90% of claims pose no risk, 2% are confirmed fraudulent, and the remaining 8% fall into a grey zone where inefficiencies and abuse remain unaddressed.

BCG notes that this mid-segment presents the biggest opportunity for the industry to curb leakages without burdening genuine policyholders.

To address these challenges, the report recommends a three-pillar framework—Prevention, Detection, and Deterrence—supported by a unified national codebook, governed GenAI tools, and real-time data exchange through platforms such as ABDM and NHCX.

These measures, it says, can accelerate India's progress toward the government’s “Insurance for All” vision under Viksit Bharat 2047.

In parallel with the report, Medi Assist announced two AI-driven platforms built on its internal AI stack. MAven Guard, a self-learning transaction integrity system, aims to detect and prevent FWA in real time, while MAgnum, a hospital enablement solution, is designed to make cashless processes smoother for members and providers. The company said these tools will strengthen service delivery while improving transparency and long-term sustainability in the health benefits value chain.

Satish Gidugu, CEO of Medi Assist, said India’s health system is at an inflection point where connected data and automation will drive the next decade of progress. “Each year, an estimated ₹8,000–10,000 crore of claim payouts leak through FWA,” he said, adding that proactive detection can help keep healthcare accessible and affordable.

BCG’s Swayamjit Mishra said next-generation digital intelligence can meaningfully reduce leakage within the 8% abuse-prone claims segment. Such efforts, he added, could advance India’s insurance penetration goals by up to five years.

The initiative marks a coordinated push toward building a more trusted, efficient, and technology-driven health benefits ecosystem.