本文從保險學之角度出發，深入探討保險契約與保險詐欺之不可分割性，闡述保險概論，說明保險契約之原理、特性、要件與制度運作等情形，逐一分析保險制度上之設計與特性，如何有遭利用、濫用之可能性。第二步說明保險詐欺之定義、成因和特徵，詳細解釋保險詐欺於我國之發展。第三步說明保險詐欺在實務上之處理模式，並討論詐欺罪可否適用保險詐欺，並探討實務上對於公共危險、詐欺罪之保險詐欺如何進行判決與判決上是否有其侷限性。第四步借鏡國外制度，介紹國外對於保險詐欺之處理方式，並詳述在刑法典上有保險詐欺之法條，作為我國立法之參考。 / This article from the point of view of insurance and in-depth discussions of the indivisibility of the insurance contract and insurance fraud, elaborate introduction to insurance, description of insurance principles, such as elements, attributes, and the system was working, individually design and characteristics analysis system of insurance, has been used, the possibility of abuse. Step description definition, causes and characteristics of insurance fraud, detailed explanation of insurance fraud in the development of our country. Step instructions processing mode of insurance fraud in the practice, and discuss fraud insurance fraud will apply, for discussion and practice of public danger, fraud insurance fraud conviction and the judgement on whether there were limitations. Fourth step learn from foreign systems, introduces the various approaches of insurance fraud, and spelled out in the criminal code on the law of insurance fraud, as a reference of our legislation.

我國強制汽車責任保險自西元1998年1月1日開始實施，迄今已逾10年之久，主要精神為使交通事故之受害人迅速獲得基本保障及維護社會大眾之安全與權益，所以採無過失責任精神，即在交通事故傷亡之受害人不論有無過失皆可獲得保險金給付，使許多受害人及其家庭之經濟即時獲得補償，所以有近九成民眾對於強制汽車責任保險之實施成效給予高度肯定。 近年來，強制汽車責任保險已成為保險犯罪集團覬覦之目標，保險詐欺案件有日益增加之趨勢，保險詐欺犯罪也發展成組織化及專業分工之保險詐欺集團，詐欺手法也不斷翻新且日益猖獗，也使強制汽車責任保險之實施精神遭受扭曲及破壞。本研究係透過產物保險業者蒐集不同類型之強制汽車責任保險詐欺案例，針對個案之犯罪手法加以比對分析，希冀從所蒐集不同類型之案例中探討保險詐欺之詐欺手法及特徵，以期研擬出一套具體措施能夠對保險詐欺作有效之防制，以遏止保險詐欺案件之發生。 本文研究有鑒於美國、英國、德國、挪威、日本及中國大陸等國家對於保險詐欺之防制不遺餘力，同時參考各國有關保險詐欺之法律規定與防制概況，保險詐欺資訊之提供及為對抗保險詐欺之教育宣導，這對於保險詐欺防制工作剛起步之我國，當有許多值得學習之處。當然保險詐欺之防制需要社會大眾、保險業者及政府檢警消相關單位正視保險詐欺問題之嚴重性，大家共同聯手一起來防制，才能有效遏阻保險詐欺之歪風。 / Compulsory automobile liability insurance in Taiwan has been implementing more than ten years since January 1, 1998. Its law-making intention is to ensure prompt and basic coverage for the injured parties in the automobile traffic accident and maintain the safety and rights for the public so it is adopted the system of no-fault basis. It means any injured party who is injured or lost of life in the automobile traffic accident can require the reimbursement regardless of who’s fault. Many injured parties and their families have received the prompt reimbursement from compulsory automobile liability insurance, so there are almost ninety percentage of the public in Taiwan giving the highly positive feedback to the implementation of compulsory automobile liability insurance. Within recent years, the compulsory automobile liability insurance which becomes a crime means and target of organized crimes of insurance fraud. The case of Insurance Fraud has the tendency in growth and the trick of insurance fraud become organized and professionalized, which has seriously affected the law-making purpose and normal developments of compulsory automobile liability insurance. This research, through the various organized criminal fraud cases of compulsory automobile liability insurance provided by non-life insurance companies. In order to prevent the fraud case from being on compulsory automobile liability insurance, this research collects and provides various types of fraud cases containing different means and characteristics. By the research, we hope to provide an effective measure to prevent fraud case from being on compulsory automobile liability insurance. The research is on the basis of the fact that many countries, for example, United States of American, England, Germany, Norway, Japan and China, have left on stone unturned to prevent insurance fraud and also on the basic of their laws and situations about insurance fraud, to furnish information about insurance fraud, and to educate the public about how to fight against insurance fraud, which is very beneficial to promote the development of insurance anti-fraud in Taiwan. There is no doubt that the prevention of insurance fraud needs the public, the insurer and authority cooperate closely. Only by doing so, we can prevent efficiently insurance fraud from spread.

中央健康保險局於2010年1月1日推動住院醫療費用採「診斷關聯群制度」的支付方式，其主要目的為控制醫療費用的不合理成長，期能拉近健保費用的收支差距，化解財務危機，並將健保財務風險轉嫁到醫療機構、或說是醫事人員來承擔。於2011年1月26日新修訂的二代健保，更擴大保費基礎，促使更多被保險人使用者付費。然而診斷關聯群制度之給付，實已包含當次住院所訂各項相關費用，故中央健保局在約佔整體健保業務支付20％的一五五項「診斷關聯群制度」內「禁止使用自費醫材」，令各醫療院所對已納入健保給付，且符合適應症者，皆不可向病患收取自費，如有尚未收載之自費項目，應先向總局申請核價，在未核價前仍不可收取自費。且健保局自2010年7月起加強審查案件，針對醫療院所向病患收取手術及特材自費之情形，將逕予不給付，並發函限期改善，未改善者，將依「全民健康保險法」、「全民健康保險醫事服務機構特約及管理辦法」辦理。 觀察世界主要先進國家的健康醫療保險制度，其「傳統醫療體制」，可約略簡化成一光譜，若其極左端為英國之「公醫制度」，則其極右端為美國之「市場化自由醫療」。相對地德國之「社會福利市場經濟醫療保險」可謂處於光譜偏左路線，日本之「國家主導的醫療保險」則屬於中間偏右。然而在近年因應情勢所迫，英國漸鬆綁公醫制度、美國努力邁向全民健保、日本強調社會共生、德國擴大自費承擔之後，各國逐漸朝向醫療體系光譜的中央移動，形成中庸路線，此可成為我國健保改革方向之借鏡。 上有政策，下有對策，醫療院所因應之道與實然之臨床面若非照舊視臨床所需，或配合健保停止使用自費醫材，或改成完全自費醫療，或變通減少使用自費醫材的比率、參雜使用自費醫材，或另設商店專櫃售醫材，讓醫療院所與自費醫材關係脫鉤。然而變通減少使用自費醫材的比率是違法行為，而參雜使用自費醫材畢竟是脫法行為。 在日益普及的私人商業醫療保險下，民眾提高商業健保附加險保費的同時無非於保險事故發生時，得到雙重保障，或多或少因此產生較高的新道德危險。醫療院所在健保局嚴苛支付制度改革下，轉型多元經營自費醫療產業，也對民眾產生新道德危險而推波助瀾地「增加」民眾利用商業醫療保險的使用率。「診斷關聯群制度」下使用自費醫材禁止則抑制被保險人追求高品質健康的理想，防堵了商業保險理賠金額提升，但對健保局降低保費的給付有限，對被保險人健康提升無助益，相反地卻可大大降低私人商業保險理賠負擔而減緩其責任。 其實健保特約的限制，不宜過度介入與變更醫療核心價值，否則會讓醫療品質退步，最終「以健保規章取代醫學教科書」。解決之道為健保局只能承擔符合健保規定之「適當醫療服務」費用，其他費用應回歸醫療契約債之本旨，讓契約兩造當事人自行處理。使用自費分擔方式可緩和健保局財務窘況，亦可分擔醫療給付的拮据。保險人應妥善健全提供符合最低人性尊嚴需求之醫療體系，至於有人無力負擔自負額，以致僅獲得較低或較危險的醫療服務，也是自由市場經濟運作下在所難免之殘酷事實。 依目前中央健保局函釋認為，納入「診斷關聯群制度」之病患，因健保局已包裹支付其醫療費用，若擅自「額外」要求病人自費，就是「實質收受全額健保給付費用、實際卻只應用部分健保支付品項」，故不得收取自費，否則有詐欺保險人之嫌。建議健保局可精算後，抽離並扣除此健保支付之主要醫材費用後，再另行公布所應支付的定額範圍，而非完全禁止自費。如斯作法只是「技術上的問題」，並非不可解決，也才不至於讓保險人、醫事服務機構、保險對象陷入僵局，可讓純粹為服務病患之醫事人員，從保險詐欺罪中解套。 醫療糾紛時最重要的是如何有效填補病患或其家屬的損害，這種民事賠償責任的確立，是處理醫療糾紛的主軸，在刑事上主要目的是在請求刑事訴訟中能附帶民事賠償。在醫事服務機構違反健保規定致保險對象損害時，保險對象只能向保險人監督機關提出「申訴」，要求糾正。然而在醫事服務機構遵照健保規定卻致保險對象損害時，如禁止納入「診斷關聯群制度」之病患使用自費醫材，若保險對象有其自費醫材之使用適應症、本身有意願使用、醫事人員也有能力提供服務，醫事人員卻礙於健保規章而使用「診斷關聯群制度」所提供之醫材，最終卻致保險對象損害之事實發生，則保險人可能具有國家賠償之責任。 基於對憲法基本人權的權衡，可知福利國家內不應全面「診斷關連群制度下自費醫材使用禁止」，而「診斷關連群制度下自費醫材使用禁止」亦是對人性尊嚴之挑戰與侵犯、平等權之背離、生存權之限制、自費醫材廠商之工作權侵害、醫學研究之學術自由迫害，如此完全無法通過比例原則的檢視考驗。 社會福利制度的建構，需要各領域的專才共同致力解決，提出更深入的檢討與批判，以促成健保制度更趨完美、人民健康更受保障。所推動之「診斷關聯群制度」應權衡諸方權益，例如健保給付醫療機構的水準高低，對病人及醫療人員醫療選擇自由限縮的程度，與廠商營業結構的影響等，事先就應該全盤考量，統合相關的法規與憲法規範意旨，並檢驗所有可能之相關基本權的限制是否踰越界限，擬定合憲政策方針後，方能依循施行之。由此可知健保局對於納入「診斷關聯群制度」下的病患禁止使用自費醫材所做的規制，仍然必須合乎憲法保障人民自由權與平等權的規範要求，不得逾越憲法第二十三條及其所蘊含之比例原則的規範要求。「禁止使用自費醫材」將會對病人醫療尊嚴、自決權與平等權，醫事人員學術自由，及自費廠商之工作權構成限制。衛生機關應就全民健保管理監督而通盤檢討改善，始符憲法建立公平、有效社會安全體制之意旨，創造出被保險人、保險醫事服務機構及保險人均能獲得三贏的局面。

保險詐欺是自有保險制度以來就有的問題，世界各國都被這個問題所困擾。因為沒有受到廣泛的宣傳及討論，加上執法機關的忽視、抗拒提供調查機能及加強追訴，所以在1980年代以前沒有被當作重大問題予以重視，一般民眾完全不知它的嚴重性，把它當作「沒有被害人的犯罪（victimless crime）」。然而保險詐欺隨時都在發生，而且範圍及程度日益擴大，已堪稱為「溫和的巨災（quiet catastrophe）」，不但影響個人經濟負擔，且破壞社會安定，因此本文就如何防制保險詐欺加以探討。 保險詐欺直接衝擊的是保險公司的經營穩定性與安全性，對保險公司而言是經營上的風險，因此從風險管理的角度，分析保險公司的實務運作，探討運用各種風險管理對策防制保險詐欺的可行性。經本文研究發覺以風險管理模式可以防制保險詐欺或減輕保險詐欺的損失，各種風險管理對策運用如下： （一） 風險自承原則：對規模小、影響層面小的保險詐欺案件，列為「堪忍的詐欺」，予以承受，以節省相關的查證經費。 （二） 風險規避原則：建立「防範保險詐欺查核表」，在進行核保、理賠作業時嚴格查核，積極避開保險詐欺風險。 （三） 風險分散原則：針對損失頻率低、損失幅度大的案件採取同業共保的方式；對損失頻率高、損失幅度小的案件採取約定自負額方式承保，以分散風險。 （四） 風險轉嫁原則：約集保險同業成立相互保險組織，把保險詐欺所帶來的風險移轉給相互保險組織。 保險詐欺基本上是犯罪行為，要消弭犯罪行為可以藉由對犯罪環境加以有效管理、設計或操作，以及降低犯罪機會達到目的。本文研究發現推動「詐欺管理生命週期理論」的嚇阻、預防、察覺、緩和、分析、政策、偵查、追溯等措施，及「情境犯罪預防理論」的增加犯罪困難度、提升犯罪風險、降低犯罪報酬、削弱犯罪動機等措施，喚起全民共同防制保險詐欺的意念，可以壓制保險詐欺之發生。 嚴謹的法令規範是防制犯罪的根本，經由本文的探討發覺保險詐欺的盛行，除了民眾法治觀念差以外，現行法令不周全，讓歹徒有機可乘及執法單位強制力不足，亦是原因之一。修訂保險法及刑法，對於防制保險詐欺有很大的效益。 / “Insurance Fraud” has been an issue, by which the countries all over the world are perplexed, since there exists the system of insurance. By 1980’s, not much attention has been paid to this issue which deemed a victimless crime and the public does not realize how serious the problem is due to the lake of broad propaganda and the ignorance, being rejected to offer the function, and being refused to strengthen prosecution by the law enforcement agency. Nevertheless, insurance fraud happens all the time and has already been called the “quiet catastrophe” because the range and severity caused keep expanding day by day. Resulting from, not only the financial burden of the individual is influenced, but the social stability is destroyed as well. Therefore, this paper probed into “how to prevent Insurance Fraud”. Since Insurance Fraud would strike the financial stability and security of an insurance company, it becomes kind of risk on company’s management. This paper would be analyzing the practical operation of an insurance company and trying to find out the feasibility of Insurance Fraud Prevention by using various kinds of risk management countermeasures. By which, this paper discovers the losses caused by insurance fraud could be prevented and/ or reduced. The followings are those risk management countermeasures studied and applied: A. The principle of “Risk Retention & Reduction”: Sorting out those cases by loss amount scale. Smaller ones are classified & named as “Admitted Fraud”, and settled without verification in order to save the related expenses for investigation. B. The principle of “Risk Avoidance or Hedging”: Setting up “Checking List of Insurance Fraud”, by using which to actively avoid the risk of insurance fraud while carrying on the operations of underwriting and claim handling. C. The principle of “Risk Sharing & Diversification”: Co-insuring with peer companies for those accounts with the characteristic of low frequency & high severity in terms of loss exposure. As to other accounts, appointing an appropriate policy deductible level to disperse the risk of Insurance Fraud. D. The principle of “Risk Transference or Shift”: Establishing the pooling system or organization to transfer the risk of Insurance Fraud to the peer companies. Basically, Insurance Fraud is a criminal offence, which could be eliminated and / or reduced by way of methods of management, design, and operation on the crime environment. It is found that the occurrence of Insurance Fraud could be depressed by: A. Promoting measures of “The Fraud Management Lifecycle Theory”, such as deterrence, prevention, detection, mitigation, analysis, policy, investigation, prosecution etc., and B. Executing the countermeasures of “The Situational Crime Prevention Theory” such as increasing perceived efforts, increasing perceived risks, reducing anticipated reward, removing excuses etc., and C. Arousing the public the thought of fighting Insurance Fraud mutually. A rigorous legal system is the base of preventing criminal offence. As discovered and presented by this paper, reasons why the Insurance Fraud has been prevailing are not only because of a poor sense of legal compliance of the public, but also the un-thoroughness of the current legal system resulting in offering ruffians opportunities to take advantages from Insurance Fraud and the in-sufficient power of prosecution of the law enforcement agency. Therefore, to revise the insurance law and criminal law would be greatly workable for preventing Insurance Fruad.