人身保險之失能扶助險理賠因子分析-以S公司為例

失能扶助險於民國104年相繼於各大保險公司推出，因以強調保證給付與保障終身為訴求，保費又比長照險相較便宜，迄今已累積數百萬張的銷量。後來因為損失率攀高，導致國外再保險公司拒保或漲價，再加上保險公司提存責任準備金不足，最後造成主管機關緊盯後，國內失能險陸續停售或改版。為找出造成申領失能扶助險理賠金之危險因子，本研究採用國內某大型金控之壽險公司(以下稱 S 公司)，由該樣本公司申領之失能扶助險理賠相關資料，並以該資料保單中申領理賠次數加以分析，探究因申領多次失能扶助險，所造成高額理賠金之相關因素。也彙整該保險公司之2015年1月至2020年11月失能扶助險理賠案件基本資料及理賠項目，並分別將這些變數包括(性別、年齡、投保險種、投保單位數、疾病名稱、就醫醫院等級、被保人居住地區、通路別、通路地區、承保條件、職業等級、險種名稱)進行統計及歸納。將上述結果分別做不同面相交叉分析，試圖找出變數之間相關性，提供保險公司理賠人員在審核不同案件時發現其中相同性或合理性，讓保險公司再失能扶助險理賠風險控管上可以更準確及更有效率。運用交叉分析及卡方檢定，針對樣本公司已申領失能扶助險之保戶進行研究，樣本分析結果發現「投保至初次申請理賠期、保額、險種名稱、疾病傷害ICD、醫院等級、招攬單位地區」皆為顯著影響理賠因素之一。

關鍵字

失能扶助險、理賠因子、交叉分析、卡方檢定

並列摘要

Since 2005, major insurance companies have rolled out their disability support insurance policies. As such policies emphasize guaranteed payment and its commitment to lifelong guarantee, in addition to a relatively cheaper insurance premium as compared with long-term care insurance, this type of insurance has accumulated millions of sales volumes. Subsequently, the increase in the loss rate resulted in the refusal of providing insurance or the increase in service prices by foreign reinsurance companies. Furthermore, insufficient responsibility allowances provided by insurance companies gave rise to the close monitoring exerted by the competent authority, ultimately resulting in domestic insurance companies either stopping the sales of disability support insurance or making drastic revisions. To find out the hazardous factors for applying the insurance claims from the disability support insurance, the study adopted a life insurance company under a large-scale domestic financial holding company (hereinafter referred to as “Company S”) as the sample. An analysis was performed on the number of applications to insurance claims based on the information related to applying the disability support insurance claims of the sampling company to explore relevant factors which attributed to the expensive insurance claims due to multiple applications for the disability support insurance’ claims. We also compiled basic information and insurance claim items of the Company’s disability support insurance claim cases from January 2015 to November 2020 while preparing statistics and induction for the variables (including gender, age, insurance category, number of insurance units, name of diseases, level of hospital visited, living area of the insured, channels, channel areas, insurance conditions, level of occupations, and name of the insurance category). We conducted cross-analysis for various aspects based on the above results. We attempted to find out the connectivity of variables to provide similarities or reasonableness for insurance claims personnel of insurance companies regarding the review of different cases, allowing insurance companies to have accurate and efficient risk control on the claims of disability support insurance. Using cross-analysis and Chi-square test, we studied the insurance customers who had applied for the claims of the disability support insurance of the sampled company. Based on the results of the sample analysis, “the period between the purchase of insurance to the application of insurance claims, amount insured, name of insurance category, ICD, level of hospitals, and areas of contracting units” are significant effective factors.