人身傷害保險詐欺案件剖析及研擬預防策略之研究

論文提要內容：保險詐騙案件層出不窮，時有耳聞，如不加以防範或審核把持不嚴格，而讓有心人士得逞，這樣對於整個保險制度的發展和生存是影響非常大的，一般保險詐騙案件如果成立，表面上看起來受害者像是保險公司，但其實其他所有善良的被保險人也同樣必須要付出相當大的代價，因為整體傷害險的損失率增加，最後就不得不調高保險費，這個結果不應由善良的被保險人承擔，且保險犯罪所付出的成本低，常因有可重覆購買，保費低廉、保障額度高，利潤也較高的特性，因此縱使保險公司懷疑案件可能涉及詐欺，往往也會因為證據上取得的困難，不得已只能給付保險理賠金，且詐欺犯罪刑度較輕，就算最後被判刑，只要不涉及人命，通常判決刑度也是相當的低，為了不使人身傷害保險成為詐欺者的犯罪工具，研擬人身傷害保險詐欺預防策略是極具必要性的。本研究除以犯罪學的理論與實證研究為基礎外，更為有效將人身傷害保險詐欺案件呈現出最真實的一面，以地方法院一審判決為樣本，搜尋2008至2017年司法院法學資料檢索系統，近10年內全台22個地方法院以「人身傷害保險」名稱進行搜尋，從第一審判決有罪的案件進行分析，再依據判決書內容以「殺人」、「意外」、「醫療」、「自殘」等保險詐欺犯罪型態做為分類，再以地區分布、罪名、事故地點、判決結果、判決刑期、投保種類、重複投保狀態、申請理賠手段、申請理賠金額、詐領金額、共犯關係、出險時距等12項目進行統計，分析犯罪共同型態，並篩選出保險詐欺犯罪因子之共通性，整合出人身傷害保險詐騙的特性，再以所得資料篩選出詐騙手法類型次數最高之前四大保險詐欺犯罪類型，研擬防制對策，再經由判決書分析及案例分析法，發現探討防制人身傷害保險詐欺犯罪的各項建議，以作為保險業界預防保險詐欺及司法單位調查是類案件的參考。

關鍵字

保險詐欺；意外傷害；傷害保險

並列摘要

Abstract: Insurance frauds happen from time to time. If preventive strategies or audit checks are not strictly carried out, fraudsters can easily find a way to benefit from insurance frauds. Such a phenomenon imposes great influences on the development and survival of the entire insurance system. Not only victims such as insurance companies suffer great losses in confirmed general insurance frauds, other kind-hearted insured parties also need to pay for such fraudulent acts from increased insurance fees resulting from increased loss rate of the overall injury insurance. The law-abiding insured parties should not be responsible for the results of fraudulent acts. With a low cost for insurance crimes, fraudsters often make use of characteristics of insurances such as repeatable purchases, low insurance fees, high value of insurance protection, relatively high interest rate, thereby imposing greater challenges in the collection of evidence. As a result, insurance companies must pay insurance claims despite suspecting the involvement of fraudulent acts. Furthermore, insurance fraudsters are lightly punished. Despite being finally convicted, verdicts are relatively low as long as no human lives are involved. In order to prevent injury insurances from becoming a tool of crime for fraudsters, it is crucial to develop preventive strategies against injury insurance frauds. This research not only bases on criminology theories and empirical researches, it also reflects upon the most realistic aspect of injury insurance frauds. By sampling first instance verdicts made by district courts, the research collected data of injury insurance frauds between 2008 and 2017 from the Law and Regulations Retrieving System by the Judicial Yuan of the Republic of China. The research conducted a search for “Injury Insurance” in the 22 district courts of Taiwan of the recent decade, and analyzed only first trial convicted cases. The cases are then categorized according to the nature of insurance frauds according to key words like “murder”, “accident”, “medical” and “self-harm” found in verdicts. The cases were then processed according to 12 items including the geographical distribution, title of crime, location of crime, verdict results, sentence, type of insurance, repeated purchase of insurance, method of application of claims, number of applied claims, amount of fraud, relationship with accomplices, length of time until successful claims, so as to discover common patterns of crime. Having found common factors of crime of insurance frauds, the research was able to spot characteristics of injury insurance frauds, and thereby listed four major types of insurance frauds based on found data. Preventive measures can thus be developed. Through analysis of verdicts and case studies, the study also suggested ways to prevent and tackle injury insurance frauds, as reference for the insurance industry and juridical bodies in the prevention and investigation of insurance frauds.