What Is Medical Insurance Fraud?

Insurance fraud is also generally called insurance crime internationally. Strictly speaking, insurance fraud has a wider meaning than insurance crime. Both parties to the insurance policy may constitute insurance fraud. Where the insured party of the insurance relationship does not abide by the principle of good faith, deliberately conceals the true situation of the subject matter of the insurance, induces the insurer to underwrite, or uses the content of the insurance contract to deliberately create or fabricate an insurance accident that causes damage to the insurance company in order to obtain insurance benefits, All are insured fraud. Any insurer who lacks the necessary solvency or conducts business without approval and uses the opportunity to formulate insurance terms and insurance rates, or exaggerates the scope of insurance liability to induce and deceive the insured and the insured, is an insurer fraud. Once insurance fraud is implemented, it will inevitably cause harmful results, and it is necessary to strictly prevent it.

Insurance fraud

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Insurance fraud is also generally called insurance crime internationally. Strictly speaking, insurance fraud has a wider meaning than insurance crime. Both parties to the insurance policy may constitute insurance fraud. Where

Insurance is an economic loss compensation and personal injury payment system that integrates social mutual assistance and science and technology. It is a stabilizer and shock absorber in modern society. This system was created spontaneously by people in social practice. It is dependent on the strength of everyone to deal with all kinds of force majeure natural disasters and accidents.

Both parties to an insurance contract may constitute insurance fraud crimes, but because governments have administratively, legally and economically

At present, the international quantitative research on insurance fraud mainly includes the measurement of insurance fraud (fraud measurement), the identification of insurance fraud (fraud detection) and the prevention of insurance fraud (fraud deterrence). The measurement of insurance fraud is to measure the fraud in the insurance market, and the identification and prevention of insurance fraud are the two countermeasures for insurance companies to treat claims fraud. The former is mainly based on the statistical analysis of claims data, which can effectively identify fraud claims. Application strategy; the latter is mainly the theoretical research of insurance contracts or the resource relocation problem of insurance companies, and the optimization of

Overview of the status of insurance fraud

With the development of the domestic insurance industry, insurance fraud has also come along and developed into a serious trend. Insurance fraud in China is mainly manifested in car insurance and health insurance. According to incomplete statistics from China Claims Network, there were 66 insurance fraud cases from March 2005 to March 2006, with an average of 5.5 cases per month. According to industry experts, the amount of insurance fraud in China accounts for between 20% and 30% of total compensation, compared with only 15% globally. In this regard, domestic scholars in the insurance field have begun to study and analyze the causes of insurance fraud and preventive measures, which will undoubtedly provide important assistance to the integrity building and anti-fraud actions of the insurance industry.

Main performance of insurance fraud

However, domestic research on insurance fraud is limited to qualitative descriptions, and basically focuses on three aspects: the characteristics, causes and prevention measures of insurance fraud. For example, the article summarizes the main performance of domestic insurance fraud:

Create an illusion and convert unjustified "loss" into insurance loss

Excess insurance

Duplicate insurance

Forge or exaggerate losses

Forgery of insurance and insurance time

Causes of insurance fraud

There are also many reasons for insurance fraud, such as the general tolerance of insurance fraud in society, the lack of integrity of policyholders, problems with the internal management system of insurance companies, and incomplete insurance laws and regulations. In response to the reasons, scholars have also proposed various preventive countermeasures, such as the social precautions mentioned: guide consumers to correctly understand the harmfulness of insurance fraud, establish a nationwide special anti-insurance fraud agency, strengthen legal construction and enforcement of anti-insurance fraud Efforts to change the business model within the enterprise, attach importance to the prevention of insurance risks, strengthen inter-bank cooperation to comprehensively combat insurance fraud, improve the insurance company's operating management system and internal monitoring and management mechanism, and improve insurance clauses to eliminate fraud liability. Recently, scholars have proposed more specific precautionary measures by drawing on foreign advanced anti-fraud technologies.

China's proposals to prevent insurance fraud and strengthen integrity

The qualitative analysis of insurance fraud by various scholars in the domestic insurance field and various precautionary methods have clarified the macro direction for the anti-fraud actions of domestic insurance companies, which is of great significance to the construction of insurance integrity. However, we should see that this is an era where data is spoken. The information mined from the data will provide important help for insurance decision-making. As Karl H. Bolch, a well-known Norwegian insurance scientist pointed out, "Generally For example, past claims records have an important role in predicting claims payments in the next few years. Moreover, different insurers have a high degree of consistency with these forecasts. "It can be seen that the historical insurance data has a role in forecasting and enlightening the future. Critical. Therefore, we believe that China needs to pay attention to the following points if there are significant achievements in the field of insurance fraud research:

Insurance companies should carefully analyze fraud cases, extract useful fraud identification fields from them, and build a database of insurance fraud cases. This data should be shared by all insurance companies.

Insurance companies should increase the number of talents with anti-fraud research and analysis. These personnel must have the knowledge and capabilities in human resources, data mining technology, insurance external consultants, statistical analysis technology, and monitoring systems. They must be able to use computer software, preset variables, and statistics. Methods such as science, mathematical analysis techniques, and geographic data mapping to establish automatic identification models to play a role in insurers making compensation decisions and combating fraud.

From a social perspective, communication channels between academia and insurance practice should be established to integrate production, learning and research. Karl H. Bolch said in Insurance Economics: "Because of the lack of insurance statistics, insurance research cannot play a mutually reinforcing role in the theoretical and empirical research commonly found in finance." The lack of information is one of the reasons for the relatively weak research on insurance fraud in China. (Finance and Insurance)