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.
| Identifer | oai:union.ndltd.org:CHENGCHI/G0091932816 |
| Creators | 林秉耀 |
| Publisher | 國立政治大學 |
| Source Sets | National Chengchi University Libraries |
| Language | 中文 |
| Detected Language | English |
| Type | text |
| Rights | Copyright © nccu library on behalf of the copyright holders |
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