人身傷害保險詐欺犯罪之研究

本研究主要探討人身傷害保險之詐欺犯罪，日趨嚴重的保險詐欺，案件數量不但逐年增加且趨於組織集團化及專業化，除了造成多起駭人聽聞的重大刑事案件外，對於社會觀感與整體社會風氣造成震盪效應，倘若保險詐欺行為無法被有效遏止，除了對良善的保險制度結構造成衝擊外，對金融市場的影響程度亦不容小覷。　　本研究藉由個案之研究，從中探討推陳出新的保險詐欺手法；針對保險詐欺及保險犯罪，目前世界各國多有透過相關之立法加以關注，而我國目前現行針對保險詐欺及保險犯罪，在罰責上仍延用我國刑法法條，並未針對保險詐欺犯罪單獨立法；與此同時，本研究亦揭露理賠人員面臨理賠申訴案件處理之困難，並分析理賠人員判決之因素，目前理賠案件的申訴率為保險公司送審新商品的主要關係要件，所以理賠品質的優劣不止會影響到保險公司的形象及業務的推展，也會影響到保險公司的營運、財務安全與永續經營，有鑑於保險公司仍缺乏對保險詐欺進行有效風險控管的手段，藉此提出建議改善保險詐欺的防制機制，以防堵不肖人士及組織犯罪集團，有恃無恐的利用條款及保險公司自我監理漏洞進行保險詐欺犯罪，故保險詐欺的風險控管需在制度完善和技術創新上加大力度，以使投機詐欺犯罪者身陷囹圄，並進微言供參。

關鍵字

傷害險保險詐欺；保險犯罪；理賠

並列摘要

This study aims to investigate the bodily injury fraud in insurance. As insurance fraud becomes more serious, the number of cases escalates and the modus operandi becomes organized and professionalized, causing many horrifying and serious criminal cases that shake social perceptions and overall social norms. Should insurance fraud be ineffectively stopped, apart from impacting the friendly structure of the insurance system, its effect on the financial market should not be overlooked. 　　Through case studies, this study investigated and inferred new modus operandi in insurance fraud. Currently, many countries have made related laws to oversee insurance fraud and insurance-related crime. However, Taiwan still uses the criminal code to penalize insurance fraud and insurance-related crimes without making specific legislation. This study also disclosed the difficulties that claim adjusters face when handling insurance claims and analyzed the determination criteria of claims adjusters. Currently, the grievance rate of claims is the main requirement relating to the new products submitted for approval by insurers. Therefore, apart from affecting the image and business promotion, the quality of claims will affect the operations, financial safety, and sustainable development of insurers. In view of the lack of effective risk control measures of insurers, this study recommended mechanisms for improving insurance fraud prevention to prevent evil people and gangs from fearlessly committing insurance fraud by exploiting the loopholes in provisions and the self-monitoring of insurers. Therefore, it is necessary to enhance the optimization and technology innovation of the system for the risk control of insurance fraud in order to capture opportunist fraud offenders and for the reference of insurers.