中文摘要:

隨著工商業進步，社會大眾對保險之依賴性愈來愈大，而各式各樣假藉保險名義詐領保險金的案件層出不窮，特別是在經濟不景氣的時後，近年來甚至有演變成集團化組織犯罪之情形。如果不能適時阻止，不僅危害保險業的發展，更會助長犯罪歪風，而當保險詐欺犯罪案件大幅度增加時，賠款亦成倍數成長，無時不在衝擊著保險這一社會保障系統。隨著保險及風險評估的基本概念逐漸興起，民眾參與購買保險契約的風氣越來越興盛，並造成保險契約的種類越來越多，而民眾的選擇性也越來越多元化，而保險詐欺手法及種類也顯得五花八門。本研究針對「商業保險」中的「保險詐欺」做深入的研究與探討。並冀望從「保險詐欺」所產生之問題，整合歸納出解決之方法，提出建議供保險公司在理賠、核保審核之參考，並希望主管機關能適時修正法條，使大眾權益獲得保障。
本研究藉由蒐集相關文獻進行定義與了解，將「集團保險詐欺」所產生之類型做歸類，並針對個案類型提出建議，主要類型有:1.自殘保險詐欺犯罪。2.假住院保險詐欺犯罪。3.謀財害命詐領保險金。4.假醫師診斷書詐領保險金；而主要建議為: 1.加強保險詐欺犯罪偵查教育訓練。2.加強警察單位與保險業者平時溝通及通報管道。3.強化財團法人保險犯罪防制中心之功能。4.保險業者應加強內部稽核及控管制度。5.建立完整迅速之保險通報系統。6.保險業者應落實查證保單上之真實簽名制度。7.設立保險犯罪專業法庭審理保險犯罪案件。8.加強保險詐欺犯罪防制教育宣導。9.加強對於相關醫療單位有關醫療證明文件之審核及督導。

英文摘要:

With the progress of industry and commerce, the public relies heavily on insurance. Various insurance frauds have been committed frequently, especially during the economic downside. In fact, organized crime is becoming common in recent years. If it cannot be stopped in a timely manner, it is not only harmful to the development of the insurance industry but also causes criminal acts to take place. When the crime of insurance fraud grows significantly, insurance claims will go up in multiples that are detrimental to the social security system. With the basic concepts of insurance and risk assessment gradually emerging, the purchasing of insurance contracts by the public is flourishing and resulting in insurance diversification, so is the choice of insurance coverage for insurance policy holders as well as the insurance fraud practices and tactics. In this study, the “Insurance Fraud” in the “Commercial Insurance” is studied and researched in-depth. Hopefully, the solutions can be integrated and summarized from the problems arising from the “Insurance Fraud” with recommendations made for the reference of insurance companies in paying claims and auditing insurance underwriting; also, hope for the competent authorities to have the governing provisions amended in a timely manner for the protection of the general public’s interests.
This study is to proceed with its definition and understanding by collecting relevant literature. “Group Insurance Fraud” is classified with recommendations made for each case. The main classifications are: (1) Self-inflicted insurance fraud, (2) Fake hospitalization insurance fraud, (3) Murder insurance fraud, and (4) Fake physician diagnosis insurance fraud. The main recommendations are: (1) enhancing insurance fraud crime investigation training and education, (2) enhancing police stations and insurance industry regular communication and reporting channels, (3) enhancing the function of the Insurance Crime Prevention Center, (4) enhancing the insurance industry’s internal audit and control system, (5) establishing a comprehensive and prompt insurance reporting system, (6) insurance industry’s substantiating a signature verification system on the insurance policy, (7) establishing special insurance crime courts to process insurance crime cases, (8) enhancing insurance fraud crime prevention training and education, and (9) enhancing the review and supervision of the relevant medical documentation of the medical units.

資料來源: https://hdl.handle.net/11296/xy6r57