How the detection of insurance fraud succeeds and fails

Abstract

Insurance fraud is a serious and growing problem, and there is widespread recognition that traditional approaches to tackling fraud are inadequate. Studies of insurance fraud have typically focused upon identifying characteristics of fraudulent claims and claimants, and this focus is apparent in the current wave of forensic and data-mining technologies for fraud detection. An alternative approach is to understand and then optimize existing practices in the detection of fraud. We report an ethnographic study that explored the nature of motor insurance fraud-detection practices in two leading insurance companies. The results of the study suggest that an occupational focus on the practices of fraud detection can complement and enhance forensic and data-mining approaches to the detection of potentially fraudulent claims.     

Control of fraud and abuse in Medicare and Medicaid.

This Comment explores issues concerning the control of fraud and abuse in health programs financed with public funds, specifically the Medicare and Medicaid programs. It summarizes the nature, scope, and possible causes of what some regard as a fraud and abuse "crisis," and points out the difficulties and obstacles facing those who attempt to develop legislative and executive action aimed at controlling fraud and abuse. Recent federal initiatives in fraud and abuse control are examined, and a brief summary of key provisions of H.R. 3 (the Medicare-Medicaid Anti-fraud and Abuse Amendments, which may prove to be a landmark piece of legislation in this area) is provided. The author emphasizes that more effective control of fraud and abuse is necessary if further expansion of government financing of health programs, including national health insurance, is to occur in the near future. At the same time, caution must be taken not to neglect the appropriate use of other mechanisms necessary for reducing the costs of medical care and improving its quality. In addition, it is likely that efforts to stem fraud and abuse will raise important medicolegal and public policy issues that will require careful interdisciplinary consideration.     

保险诈骗罪若干疑难问题探究

有关保险诈骗罪的主体争议:冒名骗赔的行为应定性为保险诈骗罪;隐名的投保人、被保险人可以成为保险诈骗罪的主体;保险人、保险经纪人、保险代理人诈骗投保人、被保险人、受益人的应定性为诈骗罪。虚构保险标的的表现:虚构根本不存在的保险标的;恶意超额保险;恶意重复保险;虚构保险利益;将不合格的标的虚构为合格的保险标的;事后保险。内外勾结共同骗取保险金的行为应一律认定为职务侵占罪或者贪污罪。     

A FIELD EXPERIMENT ON INSURANCE FRAUD IN AUTO BODY REPAIR*

This article focuses on a particular form of white-collar crime–insurance fraud in auto body repair. Through the use of an experimental design, whether repair estimates were related to insurance coverage was investigated for a statewide representative sample of auto body repair shops in Massachusetts. The auto body repair estimates were significantly higher with insurance coverage than without, regardless of type of car, extent of damage, sex of driver, and location of shop. The implication of the findings is that the automobile insurance industry is very susceptible to fraudulent or illegal practices that take unfair advantage of consumers and insurance companies.     

Testing assumptions about naivety in insurance fraud

Abstract

Despite the recognition that traditional methods of fighting the rising and pressing crime of insurance fraud are ineffective, much attention in the process of its detection is still paid to the characteristics of false claims and of people submitting them. Although there is some research looking into the assumptions insurance companies hold about these characteristics, the question of the general public knowledge about them has been rather neglected. This appears unjustified in light of the fact that it is ‘the average’ opportunistic driver most likely to lie about their loss. The results of this project, employing the method of thematic analysis, whereby the narratives of 25 male drivers are examined, challenge the correctness of corporate assumptions about what the layman driver could know about insurance fraud.     

Insurance Fraud and the Role of the Civil Law

Two UK Supreme Court decisions have considered insurance fraud. The first, Versloot Dredging BV v HDI‐Gerling Industries Versicherung (The DC Merwestone), concerned the use of a fraudulent device being harnessed to support a legitimate claim which, in the view of the majority, was an area of insurance law in need of re‐evaluation. The second, Haywood v Zurich Insurance Co, concerned the use of fraud to increase the settlement paid by the insurer and whether an insurer, which suspects fraud but has nevertheless chosen to settle a claim, is entitled to set aside the settlement under the tort of deceit where it subsequently discovers proof that it was in fact fraudulent. This case note examines not only the legal implications of the decisions and their likely impact on industry practice, it also focuses on the broader issue of the proper province of the civil law and whether general deterrence can be justified as a proper objective where the criminal law is deficient in punishing fraud because of its higher standard of proof.     

Claiming Citizenship: The Political Dimension of Welfare Fraud

This article exposes the political dimension of welfare fraud by investigating—in the context of the Israeli welfare reform of 2003—how forty‐nine Israeli women who live on welfare justify welfare fraud. I find that women's justifications cannot be fully explained by traditional noncompliance theories that view welfare fraud as an individual, private, criminal activity that solely reflects on the fraudster's moral character or desperate need. Instead, women's justifications for welfare fraud are better understood as a sociopolitical struggle for inclusion and deservedness—as a political act that reflects an alternative concept of citizenship with respect to women's unpaid care work.     

保险诈骗罪的既遂和未遂形态刍议

首先对保险诈骗罪是举动犯、行为犯,还是结果犯之争论进行分析,得出保险诈骗罪是结果犯的结论;在此基础上 介绍了该罪未遂形态的存否之争,得出保险诈骗罪存在犯罪未遂形态的结论;最后简要分析了该罪既遂形态与数 额的关系。     

论建筑物抛掷物、坠落物致害道义补偿责任——兼论建筑物抛掷物、坠落物强制责任保险制度的建立

《侵权责任法》第87条规定的建筑物抛掷物、坠落物致害补偿责任的性质不是侵权责任,也不是公平责任,而是道义补偿责任。该道义补偿责任的适用范围,受到“建筑物”、“抛掷物”或者“坠落物”和“难以确定”三个方面的限制。其责任限制又主要通过抗辩举证、数额确定及责任分担来实现。另外,建议将该道义补偿责任纳入强制责任保险的范畴,并由法定责任主体通过物业费代为征收的方式予以缴纳。     

You cannot hide your telephone lies: Providing a model statement as an aid to detect deception in insurance telephone calls

Deception research regarding insurance claims is rare but relevant given the financial loss in terms of fraud. In Study 1, a field study in a large multinational insurance fraud detection company, truth telling mock claimants (N = 19) and lying mock claimants (N = 21) were interviewed by insurance company telephone operators. These operators classified correctly only 50% of these truthful and lying claimants, but their task was particularly challenging: Claimants said little, and truthful and deceptive statements did not differ in quality (measured with Criteria‐Based Content Analysis [CBCA]) or plausibility. In Study 2, a laboratory experiment, participants in the experimental condition (N = 43) were exposed to an audiotaped truthful and detailed account of an event that was unrelated to insurance claims (a day at the motor races). The number of words, quality of the statement (measured with CBCA), and plausibility of the participants' accounts were compared with participants who were not given a model statement (N = 40). The participants who had listened to the model statement provided longer statements than control participants, truth tellers obtained higher CBCA scores than liars, and only in the model statement condition did truth tellers sound more plausible than liars. Providing participants with a model statement is thus an innovative and successful tool to elicit cues to deception. Providing such a model has the potential to enhance performance in insurance call interviews, and, as we argue, in many other interview settings.     

Coping with Precariousness: How Social Insurance Law Shapes Workers' Survival Strategies in Vietnam

This article examines the role of social insurance law in the survival strategies of factory workers in Vietnam, especially when they are faced with pressing family needs and an uncertain future. Despite the official discourse of the law which encourages employees to accumulate social insurance for their pension benefits, workers in this study have considered their social insurance fund as a form of saving and opted to gain early access to it when they are in desperate need of money. Workers understand and use the law in a way that answers to their needs; however, such action simultaneously puts them outside the protection of the law. In workers' daily struggles, law generates a moral tension between rights and needs, and ultimately perpetuates their precarious, vulnerable condition. The article demonstrates how workers' legal consciousness varies according to their perception of their precariousness, a precariousness generated by the fragile nature of their work and underpinned by their traditional familial moral obligations. This research advances our understanding of the way state law in postsocialist regimes informs social action and consciousness in ways that oftentimes contradict the spirit of the law.     

Victims’ motivations for reporting to the ‘fraud justice network’

ABSTRACT

It is well-established that (online) fraud has one of the lowest reporting rates across all crime categories. However, there is a large gap examining why some victims choose to report online fraud offenses. Therefore, this paper examines the under-researched group of online fraud victims who reported their crimes to authorities. Based on interviews with 80 victims across Australia, who lost at least AUD10,000 to online fraud, this paper demonstrates two motivations behind reporting: a sense of individual justice, and an altruistic notion of protecting others. The paper also highlights the negativity associated with the reporting process. The paper uses these findings to determine what can be learnt from the victims who were willing to report. It concludes with a discussion of the challenges evident in seeking to improve the confidence of victims reporting to authorities.     

Shipping and scuttling: Criminogenesis in marine insurance

Among the instances of maritime fraud, the scuttling of ships, the deliberate sinking of a ship in order to collect the insurance money, stands out. It has been suggested that marine transport is prone to infiltration by organized crime groups. These are suggestions that have never been substantiated, but they could point towards a criminogenic market-structure of the (marine) insurance industry. The Dutch marine insurance-industry has a reputation to lose. The insuring of ships requires skill, professionalism and money, but the practice of marine insurance has hardly changed since the Dutch Golden Age. Drawing upon the results of two years of fieldwork in the Dutch marine insurance industry, it will be argued that the scuttling of ships is interlinked and intertwined with the practice of marine insurance and the way the marine insurance industry is commercially and legally organized. An analysis of the opportunity-for-fraud-structure of the (Dutch) marine insurance market will be made. This revised version was published online in August 2006 with corrections to the Cover Date.     

论重复保险——兼评我国《保险法》第41条之缺失

重复保险制度作为保险法律中一项防范投保人道德危险的基本制度,对保险功能的发挥具有重要意义。但是,我国重复保险的法律规定存在着诸多漏洞和不足。缺乏对违反通知义务法律后果的规定,缺乏恶意复保险的规定和重复保险的保险费处理方式的规定,另外,重复保险的适用范围不清、法律效力规定不恰当等,也导致了该制度无法正常发挥应有的效用。     

2001年我国海事法学研究综述

本文整理归纳了 2 0 0 1年我国海事法学的论文 ,并将其按船舶物权法、海上货物运输法、海事法、海运欺诈、海上保险、海事诉讼与仲裁等 6个方面进行综述和简要评论 ,并对我国海事法学今后的发展提出了希望。     

关于信用证欺诈例外的若干问题研究

信用证的独立性 (或自主性 )原则是信用证体系赖以生存和发展的根本性原则 ,依据该原则信用证及相关的单据与合同交易是分离的。但是这种机制为受益人从事欺诈行为创造了条件 ,基于此 ,各国逐渐地发展了遏制信用证欺诈的重要制度———信用证欺诈例外。本文拟对欺诈例外的涵义及特征作一分析 ,并就欺诈例外适用中的何谓“欺诈”、欺诈例外适用的排除、开证行应如何应对欺诈例外、欺诈例外与法院禁付令的关系等重要问题进行探讨 ,并在评论我国司法实践中存在的问题的基础上 ,就我国相关法制的完善问题作一思考。     

New directions in policing fraud: The emergence of the counter fraud specialist in the United Kingdom

Fraud and corruption in the public sector have become issues of increasing importance for the government in the United Kingdom. Numerous initiatives have emerged ranging from high profile publicity campaigns against benefit fraud and tax evasion to the establishment of specialist bodies, such as the NHS Counter Fraud and Security Management Service (NHSCFSMS). One of the most interesting developments, however, has been the emergence of the ‘counter fraud specialist (CFS)’ across central and local government, as well as the private sector. These are specially trained civilian personnel who are tasked to prevent, investigate and secure sanctions against fraudsters. They undertake common training packages and are accredited by the Counter Fraud Professional Accreditation Board (CFPAB). This paper first outlines the emergence of the CFS; then draws upon the results of recent survey data to discuss some of their characteristics. The paper also considers some of the main issues raised by the growth of the CFS including the possible emergence of an embryonic ‘fraud police’, the indirect ‘load shedding’ of fraud investigation and the governance of this new breed of policing personnel.     

集资诈骗罪“非法占有目的”要件的理论修正与司法检视

传统非法占有目的理论难以对集资诈骗罪中反复的"借款-还款"行为予以精准定性。"排除意思"既不是诈骗罪主观层面的要素,也无法适用于持续还本付息的集资诈骗行为。"利用意思"和"不法获利"不能用以区分集资诈骗罪与非法吸收公众存款罪,无法发挥"非法占有目的"应有的罪名界分功能。非法占有目的并非集资诈骗罪的独立构成要件,以集资诈骗故意统摄本罪的主观要件并规范化解释为财产损害故意,能够完整地发挥定罪和罪名区分功能。以不具有债务履行能力和意愿推定财产损害故意,不仅符合理论逻辑,也能够通过司法实践的检验。     

存款保险制度下银行道德风险的法律控制

存款保险制度下的道德风险包括存款人道德风险、银行道德风险、监管机构道德风险,而银行的道德风险是其道德风险问题最集中的体现。因此,在我国即将建立的存款保险制度之际,有必要借鉴美国的立法改革经验,在存款保险制度下,通过让存款人、投保银行和监管者都投入一定资源的法律制度安排,加强对商业银行道德风险的控制,同时还必须通过完善银行治理结构,严格信息披露制度,培育良好的存款保险理念,审慎的监督等其他制度措施与之相配合。