論人身保險智慧型詐欺之型態及防制之道

Type and prevention method for the intelligent life insurance fraud

李思穎(Szu-Yin Li)

指導教授 ： 郝充仁

共同指導教授 ： 李雅婷

淡江大學/商學院/保險學系保險經營碩士在職專班/碩士(2011年)

https://doi.org/10.6846/TKU.2011.00163

摘要

鑒於人身保險詐欺的手法不斷翻新，僅依靠保險業間彼此互相聯繫是不足以來防制保險詐欺犯罪。保險公司、公會、保險犯罪防制中心與政府機關應建立聯繫機制及合作，透過公務部門的力量如與警方、健保局間合作偵辦。此種相互合作的模式，在國外如英國、美國等先進國家已能有效降低保險詐欺之案件與損失。
本研究主要是先歸納出智慧型人身保險詐欺之特徵，再從理賠案例發現保險招攬、核保、理賠等作業過程中所產生問題，以及借鏡國外較獨特防制保險詐欺之作法，希能應用於國內人身保險詐欺之防制上。
最後，對於我國現行保險詐欺防制機制不足的部份，分別以保險公司及監理機構之角度，嘗試提出具體建議如下，以期達到積極防阻、避免重蹈覆轍及減少損失擴大等效果。
一、從保險公司角度
（一）成立保險犯罪理賠防制部門。
（二）製定保險犯罪教育訓練之最低時數。
（三）落實保險公司內稽、內控制度。
（四）設計保險新商品應更嚴謹。
（五）檢討現行通報制度及建置理賠網路通報系統。
（六）與相關單位保持密切合作，並建立海外聯繫管道。
二、從監理機構角度
（一）推廣保險詐欺防制的觀念
（二）制定保護保險犯罪防制人員之相關法律
（三）保險詐欺入罪化
（四）保險法明文規定違反道德危險之特別終止權

關鍵字

理賠 ； 保險詐欺 ； 道德危險

並列摘要

Given the way life insurance fraud is ever-changing, only relying on the contact between each insurance industry is not enough to prevent the insurance fraud crime. Insurance companies, insurance associations, Insurance Anti-Fraud Institute (IAFI) and Government should cooperate and establish a communication with each other to fight against crime through government apartments, such as Police Force and Bureau of National Health Insurance. This cooperation way has been applied in other countries such as Britain, United States and other developed countries. Also, it has been approved that the insurance fraud crime is reduced effectively.
In this study, the characteristics of intelligent life insurance fraud is summarized and investigate the raising problem of solicitation, underwriting and claims through different cases In addition, we learn the effective prevention method of insurance fraud from other countries and hope it can be applied to our country to prevent the life insurance fraud.
From the view of insurance company and supervision institution, we provide some recommendations about the prevention way of insurance fraud as below to hope the loss due to insurance fraud can be reduced.
1. The view of the insurance company.
(A) Set up an insurance claim of crime control department.
(B) Set up the minimum training hours of insurance education.
(C) Implementing the insurance company internal audit and control system.
(D) Rigorously design for new insurance products.
(E) Reviewing the current notification system and network building claims reporting system.
(F) Maintain close cooperation with relevant units, and establish overseas contacts channel.
2. The view of supervisory agencies.
(A) Promote the concept of Insurance Fraud Prevention.
(B) Develop the personnel protection laws for the investigator of Insurance Crime Prevention.
(C) Convicted of insurance fraud.
(D) Clearly express to terminate the right for the immoral behavior on Insurance Law.

並列關鍵字

Claim ； Insurance Fraud ； Morality Risk

參考文獻

1.韋俊青(2005)。我國人身保險詐欺集團犯罪及壽險公司防制對策之研究』。碩士論文，淡江大學保險學系保險經營碩士在職專班。

2.黃俊豪(2005)。『醫療保險詐欺之研究』，碩士論文，淡江大學保險學系保險經營碩士在職專班。

4.林天轟(2010)。『我國壽險理賠調查之探討及實例分析』，碩士論文，淡江大學保險學系保險經營碩士在職專班。

3.傅建承(2007)。『壽險業保險犯罪之研究』，碩士論文，淡江大學保險學系保險經營碩士在職專班。

5.陳泊文(2010)。『人身保險詐欺之研究與對策』，碩士論文，淡江大學保險學系保險經營碩士在職專班。