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.

This diploma thesis deals with problems of insurance fraud in the Czech Republic. The thesis is decided into the several separate parts. The teoretical part describes characteristics of insuracne fraud itselfs, its classification, profile of fraud perpetor and reason of committing instance fraud at all. The next part describes detection of insurance fraud and the subsecvent procedure in investigating insurance fraud. The goal of practical part of diploma thesis is analysis of insurance fraud and questionnaire survey. There will be describe the prevetion of insurance fraud and in the end, there will be several specific cases of insurance fraud.

This diploma thesis deals with the problems of insurance fraud in our society. The thesis is divided into several relatively separate sections. The theoretical part describes a basic characteristic, classification and origins of insurance fraud and it deals with a general description of perpetrators of fraudulent actions. An analysis of fraudulent actions in life and non-life insurance is carried out in the theoretical part of the diploma thesis. This work characterises the importance and the mutual relationship between detection and investigation of fraudulent actions. It also highlights the facts which aid and abet insurance fraud. The aim of the practical part of the diploma thesis was to carry out an analysis of various insurance fraud cases in the realm of motor insurance according to the subject, object and the most frequent variants of fraudulent actions and consequently create a profile of the perpetrator of insurance fraud on the basis of the evaluation of the analysis. The practical case study of client’s expedient behaviour enables us to look on detection of the particular insurance fraud. The end of the diploma thesis deals with recommendations for the measures which should be taken to fight insurance fraud.

The use of analytical techniques for fraud detection and the design of fraud detection systems have been topics of several research projects in the past and have seen varying degrees of success in their practical implementation. In particular, several authors regard the use of credit risk scorecards for fraud detection as a useful analytical detection tool. However, research on analytical fraud detection for the South African insurance industry is limited. Furthermore, real world restrictions like the availability and quality of data elements, highly unbalanced datasets, interpretability challenges with complex analytical techniques and the evolving nature of insurance fraud contribute to the on-going challenge of detecting fraud successfully. Insurance organisations face financial instability from a global recession, tighter regulatory requirements and consolidation of the industry, which implore the need for a practical and effective fraud strategy. Given the volumes of structured and unstructured data available in data warehouses of insurance organisations, it would be sensible for an effective fraud strategy to take into account data-driven methods and incorporate analytical techniques into an overall fraud risk assessment system. Having said that, the complexity of the analytical techniques, coupled with the effort required to prepare the data to support it, should be carefully considered as some studies found that less complex algorithms produce equal or better results. Furthermore, an over reliance on analytical models can underestimate the underlying risk, as observed with credit risk at financial institutions during the financial crisis. An attractive property of the structure of the probabilistic weights-of-evidence (WOE) formulation for risk scorecard construction is its ability to handle data issues like missing values, outliers and rare cases. It is also transparent and flexible in allowing the re-adjustment of the bins based on expert knowledge or other business considerations. The approach proposed in the study is to construct fraud risk scorecards at entity level that incorporate sets of intrinsic and relational risk factors to support a robust fraud risk assessment. The study investigates the application of an integrated Suspicious Activity Assessment System (SAAS) empirically using real-world South African insurance data. The first case study uses a data sample of short-term insurance claims data and the second a data sample of life insurance claims data. Both case studies show promising results. The contributions of the study are summarised as follows: The study identified several challenges with the use of an analytical approach to fraud detection within the context of the South African insurance industry. The study proposes the development of fraud risk scorecards based on WOE measures for diagnostic fraud detection, within the context of the South African insurance industry, and the consideration of alternative algorithms to determine split points. To improve the discriminatory performance of the fraud risk scorecards, the study evaluated the use of analytical techniques, such as text mining, to identify risk factors. In order to identify risk factors from large sets of data, the study suggests the careful consideration of both the types of information as well as the types of statistical techniques in a fraud detection system. The types of information refer to the categories of input data available for analysis, translated into risk factors, and the types of statistical techniques refer to the constraints and assumptions of the underlying statistical techniques. In addition, the study advocates the use of an entity-focused approach to fraud detection, given that fraudulent activity typically occurs at an entity or group of entities level. / PhD, Operational Research, North-West University, Vaal Triangle Campus, 2011

The use of analytical techniques for fraud detection and the design of fraud detection systems have been topics of several research projects in the past and have seen varying degrees of success in their practical implementation. In particular, several authors regard the use of credit risk scorecards for fraud detection as a useful analytical detection tool. However, research on analytical fraud detection for the South African insurance industry is limited. Furthermore, real world restrictions like the availability and quality of data elements, highly unbalanced datasets, interpretability challenges with complex analytical techniques and the evolving nature of insurance fraud contribute to the on-going challenge of detecting fraud successfully. Insurance organisations face financial instability from a global recession, tighter regulatory requirements and consolidation of the industry, which implore the need for a practical and effective fraud strategy. Given the volumes of structured and unstructured data available in data warehouses of insurance organisations, it would be sensible for an effective fraud strategy to take into account data-driven methods and incorporate analytical techniques into an overall fraud risk assessment system. Having said that, the complexity of the analytical techniques, coupled with the effort required to prepare the data to support it, should be carefully considered as some studies found that less complex algorithms produce equal or better results. Furthermore, an over reliance on analytical models can underestimate the underlying risk, as observed with credit risk at financial institutions during the financial crisis. An attractive property of the structure of the probabilistic weights-of-evidence (WOE) formulation for risk scorecard construction is its ability to handle data issues like missing values, outliers and rare cases. It is also transparent and flexible in allowing the re-adjustment of the bins based on expert knowledge or other business considerations. The approach proposed in the study is to construct fraud risk scorecards at entity level that incorporate sets of intrinsic and relational risk factors to support a robust fraud risk assessment. The study investigates the application of an integrated Suspicious Activity Assessment System (SAAS) empirically using real-world South African insurance data. The first case study uses a data sample of short-term insurance claims data and the second a data sample of life insurance claims data. Both case studies show promising results. The contributions of the study are summarised as follows: The study identified several challenges with the use of an analytical approach to fraud detection within the context of the South African insurance industry. The study proposes the development of fraud risk scorecards based on WOE measures for diagnostic fraud detection, within the context of the South African insurance industry, and the consideration of alternative algorithms to determine split points. To improve the discriminatory performance of the fraud risk scorecards, the study evaluated the use of analytical techniques, such as text mining, to identify risk factors. In order to identify risk factors from large sets of data, the study suggests the careful consideration of both the types of information as well as the types of statistical techniques in a fraud detection system. The types of information refer to the categories of input data available for analysis, translated into risk factors, and the types of statistical techniques refer to the constraints and assumptions of the underlying statistical techniques. In addition, the study advocates the use of an entity-focused approach to fraud detection, given that fraudulent activity typically occurs at an entity or group of entities level. / PhD, Operational Research, North-West University, Vaal Triangle Campus, 2011

Insurance fraud is perhaps one of the most pressing problems challenging the insurance industry. The judiciary plays a significant role in tackling insurance fraud: the burden is on their shoulders to identify the appropriate legal rules governing fraudulent claims and determining the consequences of fraud. However, regrettably, this process has long remained elusive and in the recent decades the courts have tried but failed to formulate clear principles for the treatment of insurance fraud, so the process is, still, continuing. This judicial process is not free from difficulty particularly with regard to the consequence of presenting fraudulent claims. The failure of judicial attempt to formulate clear principles in this jurisdiction has attracted the attention of the Law Commissions which intend to pursue a reform at the legislative level. At the current stage, the law seems to stand at a turning point and try to adapt itself to the new situation. The author is of the opinion that this is the right time to provide a full-scale research in the jurisdiction of insurance fraudulent claims for the purpose of identifying the existing difficulties and confusions, shaping the appropriate legal regime and contributing to the evolving reform process of English insurance contract law. The author is also of the opinion that considering the viability of reform proposals from a novel perspective, namely economics and law, might add a very interesting dimension to the debate. It is believed that the law and economics debate would be helpful in explaining the outcomes of certain legal solutions and identifying the most appropriate legal remedy. Finally, the author also intends to examine to what extent the Law Commissions' proposal could be defended in the light of author's legal and economic analysis.

The current thesis examined the relationships between personality and attitudes and behaviours related to insurance claims, insurance fraud, and credit use. The thesis incorporates a systematic literature review of Impulsivity-related personality traits. This review led to the identification and development of a six factor framework of Impulsivity-related traits (Impetuousness, Self-Regulation, Deferred-Gratification, Consideration of Future Consequences or CFC, Attention, and Sensation Seeking). The framework was subsequently used to classify existing “Impulsivity” measures so that coherent review of research linking “Impulsivity” to financial behaviour could be undertaken. The framework guided review revealed that four Impulsivity-related traits (Impetuousness, Self-Regulation, Deferred-Gratification, CFC) appeared to be influential across a number of financial behaviours and as a result could be considered somewhat ‘central’ to financial behaviour. Accordingly, these four traits were assessed in each of the three empirical studies. In addition, each study also included a number of outcome specific traits. These were traits likely to be of importance to the specific outcome variables in each study but were unlikely to be related to economic behaviour across multiple domains. In Study 1 (n = 377), the central Impulsivity-related traits and the outcome specific traits of Compulsivity, Oppositionality, Risk-Taking, and Sensation Seeking were assessed in relation to Attitudes Towards Insurance Claims and the number of previously submitted motor and home insurance claims. The results revealed that Deferred-Gratification, CFC and Self-Regulation accounted for 36% of the variance in Attitudes Towards Insurance Claims, whilst a combined demographic, attitude and personality model was able to correctly classify participants as previous claimants or non-claimants in 84% of cases for motor claims and 66% of cases for home claims. In Study 2 (n = 475), the central Impulsivity-related traits and the outcome specific traits of Callousness, Conduct Problems, Dishonest-Opportunism, Integrity, Machiavellianism, and Pessimism were assessed in relation to Attitudes Towards Insurance Fraud and previously submitted motor and home insurance claims. The results revealed that Dishonest-Opportunism, Consideration of Future Consequences, Pessimism, Age and Educational Attainment accounted for 58% of the variance in Attitudes Towards Insurance Claims, whilst a combined demographic, attitude and personality model was able to correctly classify participants as previous claimants or non-claimants in 78% of cases for motor claims but did not predict home claims. In Study 3 (n = 611), the central Impulsivity-related traits and the outcome specific traits of Anxiety, Compulsivity, Insecure Attachment and Narcissism, were shown to be differentially predictive of five self-report financial behaviour factors (Irresponsible Spending, Financial Planning, Emotional Spending, Impulsive Credit Use and Poor Credit Management; 30-50% variance explained), the number of credit cards and loans owned (≈22% variance explained), and debt (11-15% variance explained). Finally, the personality traits were seated within a meditational model of: Personality → Credit Acquisition and Financial Behaviour → Debt. This model was strongly supported and accounted for 26% of the variance in loan debt and 31% of the variance in credit card debt.

The thesis deals with insurance fraud in connection with the economic crisis. The first chapter describes the moral hazard, adverse selection and information asymmetry. Focus on the topic global financial crisis. Further, the concepts fraud and insurance fraud are explained. The main focus of this work is that the financial crisis has led to an increase in insurance fraud and what aspects lead to this fact. The last chapter deals with the procedures of insurance companies, which seek to insurance fraud detection, prevention and repression. This chapter is a description of the settlement of claims, insurance fraud investigation, which includes the characteristics of fraud perpetrators. The last part is dedicated to the prevention and repression of insurance fraud.

This diploma thesis deals with a problem of insurance frauds in context with manipulated events. It describes the possible causes of committing this crime and the possibility of detection. In conjunction with the objectives of this thesis was carried out extensive experiments of mechanical damage of car bodies with defined tools. Origin of damage and its character were assessed in mechanoskopical terms. After that intentional damage of vehicles was compared with the declared traffic accidents and similar damage occurring at parked vehicles. This part can be used to create at a comparative database of intentional damage to vehicles in solving the technical acceptability of damage that is suitable material for use as an expert activities.

Diploma thesis deals with fighting insurance fraud from the very beginning to the end, seen from insurance company's perspective. It also tries to see insurance frauds and dealing with them not only from IT point of view, but also accompany other department's views and needs. It's starting with organizational overview and its readiness to fight fraud and trying to show, how to improve. Furthermore it introduces reader with basic terms and phrases of insurance fraud and continues with general description of this encounter. It continues with indicators of insurance fraud and its examples and strategies, how to find them in data. Next part of my thesis is focusing on available external sources and possible insurance companies' cooperation, for maximized ability to detect suspicious cases. This is continued by selection of proper system, requirements definition and its goals. Last part shows one of FMS solutions and its description, from requirements up to complete solutions architecture and screenshots of given system.