保险，骗保的有关英语说法 各种保险的英语说法

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Detecting insurance fraud

The detection of insurance fraud generally occurs in two steps. The first step is to identify suspicious claims that have a higher possibility of being fraudulent. This can be done by computerized statistical analysis or by referrals from claims adjusters or insurance agents. Additionally, the public can provide tips to insurance companies, law enforcement and other organizations regarding suspected, observed, or admitted insurance fraud perpetrated by other individuals. Regardless of the source, the next step is to refer these claims to investigators for further analysis.

Due to the sheer number of claims submitted each day, it would be far too expensive for insurance companies to have employees check each claim for symptoms of fraud.[45] Instead, many companies use computers and statistical analysis to identify suspicious claims for further investigation.[46] There are two main types of statistical analysis tools used: supervised and unsupervised.[45] In both cases, suspicious claims are identified by comparing data about the claim to expected values. The main difference between the two methods is how the expected values are derived.[45]

In a supervised method, expected values are obtained by analyzing records of both fraudulent and non-fraudulent claims.[45] According to Richard J. Bolton and David B. Hand, both of Imperial College in London, this method has some drawbacks as it requires absolute certainty that those claims analyzed are actually either fraudulent or non-fraudulent, and because it can only be used to detect types of fraud that have been committed and identified before.[45]

Unsupervised methods of statistical detection, on the other hand, involve detecting claims that are abnormal.[45] Both claims adjusters and computers can also be trained to identify "red flags", or symptoms that in the past have often been associated with fraudulent claims.[47] Statistical detection does not prove that claims are fraudulent; it merely identifies suspicious claims that must be investigated further.[45]

Fraudulent claims can be one of two types:[48]

    they can be otherwise legitimate claims that are exaggerated or "built up", or
    they can be false claims in which the damages claimed never actually occurred.

Once a built up claim is identified, insurance companies usually try to negotiate the claim down to the appropriate amount.[49] Suspicious claims can also be submitted to "special investigative units", or SIUs, for further investigation. These units generally consist of experienced claims adjusters with special training in investigating fraudulent claims.[50] These investigators look for certain symptoms associated with fraudulent claims, or otherwise look for evidence of falsification of some kind. This evidence can then be used to deny payment of the claims or to prosecute fraudsters if the violation is serious enough.[51]

When an insurance company's fraud department investigates a fraud claim, they frequently proceed in two stages: pre-contact and post-contact.[52] In the pre-contact stage they analyze all available evidence before they contact the suspect. They may review submitted paperwork, reach out to third parties, and gather evidence from available sources. Then, in the "post-contact" stage, they interview the suspect to gather more information and, ideally, obtain an incriminating statement. Insurance fraud investigators are trained to question the suspect in a way that precludes the suspect raising a valid defense at a later time. For example, questions about access to claim forms preclude the defense of another individual filling out the fraudulent documents. Common defenses that the suspect interview may preclude include the suspect lacking either the knowledge that their statement was false[53] or the intention to defraud,[54] or the suspect making an ambiguous statement that was later misinterpreted.[55] Full disclosure may add credibility to a suspect's account of events, but omissions from disclosure or false statements may detract from the suspect's credibility in later interviews or proceedings.[55]

Within the context of health insurance, fraud by health insurance companies is sometimes found by comparing revenues from premiums paid against the expenditure by the health insurance companies on claims. For example, in 2006 the Harris County Medical Society, in Texas, had a health insurance rate increase of 22 percent for "consumer-driven" health plans from Blue Cross and Blue Shield of Texas. This was despite the fact that during the previous year, Blue Cross had paid out only 9 percent of the collected premium dollars for claims.[25]

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Legislation

National and local governments, especially in the last half of the twentieth century, have recognized insurance fraud as a serious crime, and have made efforts to punish and prevent this practice. Some major developments are listed below:
United States

    Insurance Fraud is specifically classified as a crime in all states, though a minority of states only criminalize certain types (e.g. Oregon only outlaws Worker Compensation and Property Claim fraud).[14]
    The Coalition Against Insurance Fraud was founded in 1993 to help fight insurance fraud. This organization collects information on insurance fraud, and is the only anti-fraud alliance speaking for consumers, insurance companies, government agencies and others. Through its unique work, the Coalition empowers consumers to fight back, helps fraud fighters better detect this crime and deters more people from committing fraud. The Coalition supports this mission with a large and continually expanding armory of practical tools: Information, research & data, services and insight as a leading voice of the anti-fraud community.
    Approximately one third of these investigations result in criminal conviction, one third result in denial of the claim, and one third result in payment of the claim.[48]
    19 states require mandatory insurer fraud plans. This requires companies to form programs to combat fraud and in some cases to develop investigation units to detect fraud.[14]
    41 states have fraud bureaus. These are law enforcement agencies where "investigators review fraud reports and begin the prosecution process."[14]
    Section 1347 of Title 18 of the United States Code states that whoever attempts or carries out a "scheme or artifice" to "defraud a health care benefit program" will be "fined under this title or imprisoned not more than 10 years, or both." If this scheme results in bodily injury, the violator may be imprisoned up to 20 years, and if the scheme results in death the violator may be imprisoned for life.[56]

Besides making laws more severe, Legislation has also come up with a list for management that should be implemented so that companies are better suited to combat the possibility of being scammed. That list includes:

    Understanding that fraud does exist and that there is a high possibility for it happening.
    Being fully aware of the dangers and severity of the problem.
    Understanding the importance of the hiring process and how important it is to hire honest individuals.
    Learn to deal with the economic side of business. That means putting procedures and policies in place to catch and deal with individuals trying to commit fraud.[57]

Canada

    The Insurance Crime Prevention Bureau was founded in 1973 to help fight insurance fraud. This organization collects information on insurance fraud, and also carries out investigations. Approximately one third of these investigations result in criminal conviction, one third result in denial of the claim, and one third result in payment of the claim.[58]
    British Columbia's Traffic Safety Statutes Amendment Act of 1997 states that any person who submits a motor vehicle insurance claim that contains false or misleading information may on the first offence be fined C$25,000, imprisoned for two years, or both. On the second offense, that person may be fined C$50,000, imprisoned for two years, or both.[59]

United Kingdom

    A major portion of the Financial Services Act 1986 was intended to help prevent fraud.[60]
    The Serious Fraud Office, set up under the Criminal Justice Act 1987, was established to "improve the investigation and prosecution of serious and complex fraud."[60]
    The Fraud Act 2006 specifically defines fraud as a crime. This act defines fraud as being committed when a person "makes a false representation", "fails to disclose to another person information which he is under a legal duty to disclose", or abuses a position in which a person is "expected to safeguard, or not to act against, the financial interests of another person". This act also defines the penalties for fraud as imprisonment up to ten years, a fine, or both.[61]
    A task force that specializes in tracking criminals who knowingly commit fraud.[62]

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See also

    Federal Bureau of Investigation
    Florida Division of Insurance Fraud
    Horse murders
    Split billing
    United States Postal Inspection Service

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Do you know anyone who's been involved in an automobile accident and suddenly needed to wear a neck brace everywhere...except when no one else is around? Do you know anyone who's been injured on the job and, while he can't make it to work, can still accept his best friend's invitation for a weekend of skiing? These people are cheating insurance companies, and cheating insurance companies, also known as insurance fraud, is illegal.

Sadly, cheating insurance companies is a fairly common practice. People cheat other people's insurance companies by suing for injuries that didn't occur; hence the need for the neck brace. People cheat their own insurance companies, or the insurance companies of their employers such as worker's compensation, when they claim to be too injured to work but are actually well enough to do everything else.

People who cheat insurance companies aren't just cheating the insurance companies; they're also cheating everyone else who owns an insurance policy through that income. You see, insurance companies are so fed up with, and drained by, those who cheat them that the cost of insurance policies raises. That means while these people are busy cheating insurance companies, honest people are busy spending more money on insurance than they should have to spend.

Since cheating insurance companies has become such a fairly common practice, many insurance companies are cracking down by investigating the "injuries" much more thoroughly than ever. Some insurance companies hire private investigators to keep surveillance on those they think may be cheating their company. This can be a pretty effective way of cutting down on insurance fraud since most people don't expect an insurance company to go out of its way and fork over even more cash to have them investigated. Therefore, the people who are actually cheating the insurance companies freely enjoy their newfound money or free paychecks and make it much easier for the insurance companies to bust them.

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