論保險內部詐欺之防治─以保險人之內稽內控為出發點

Abstract

保險詐欺一詞，於我國學說上一直以來都廣為討論，然而定義亦多有爭執、眾說紛紜，故本文之首要目標乃參照各相關文獻並界定何謂保險詐欺。而保險制度運作之參與者眾多，不論保險詐欺之施行者為外部抑或內部人員，都將造成保險人財產上與名譽上之損失，將詐欺者之身分預設為保險公司外部人員之見解已逐漸無法應付越來越多變的保險詐欺型態，相較於外部人員之詐欺，內部人員之詐欺手段通常更為複雜，亦不以操縱保險契約之各環節為限，保險人面對內部詐欺之挑戰應如何因應便成了一值得探討的疑問。\n本文將先探討內部控制制度理論之起源與發展歷程，並以之為基礎，由其五要素之核心概念為出發，觀察其如何幫助企業在營運、遵循與匯報方面維持一定水準，再分析內部稽核制度、三道防線理論如何輔助內部控制制度之維持效能與進行分工。又內部詐欺是由保險人內部職業人員所施行之詐欺行為，為求防治措施之完整性，本文進一步嘗試以職業人員詐欺防治之框架所列之程序作為阻斷保險內部詐欺之方法，並觀察出內稽內控制度與職業人員詐欺防治框架，二者於歷史之發展上係有匯流之趨勢，並就匯流後之詐欺風險管理框架歸納出所有必備之防治程序要素。\n鑒於內稽內控制度與職業人員詐欺防治框架皆起源於美國，是本文以其兩部示範法規範為主要參酌對象，即保險詐欺防治示範法與保險詐欺示範法，最後綜合詐欺風險管理框架之理論與美國法之經驗對我國保險業內部控制及稽核制度實施辦法、保險業保險詐欺風險管理工作指引提出改進建議，希望藉此完善我國制度對保險內部詐欺防治之規範，同時促成整體保險業反詐欺環境之形成。

Although the term insurance fraud has been widely discussed in doctrines, disputes on the definition of insurance fraud still remain. Therefore, the primary goal of this article is to refer to relevant documents and define what insurance fraud is.\nIn the process of defining insurance fraud, it is not hard to find that the focus point of doctrines is always put on the external fraud, even though both insider and outsider of the insurer may engage in insurance fraud. Moreover, the means of internal insurance fraud are usually more complicated compared with the external insurance fraud, which is, presupposing the identity of the fraudster as an outsider of the insurance company has gradually been unable to cope with the ever-changing types of insurance fraud. How the insurer should respond to the challenge of internal fraud has become a question worthy of discussion.\nThis article will discuss the origin and development of the internal control theory, and based on it, observing how it can help organization to reach the objectives of operation, compliance and reporting with it’s core concept of its five components, and then analyzes how the internal audit and the theory of the three lines of defense assist the effectiveness of the internal control and the assignment of roles and responsibilities.\nFurthermore, due to internal fraud is a fraud committed by the insurer’s staff, this article attempts to use the procedures listed in the prevention and detection of occupational fraud as a method to block internal insurance fraud, and discovers that the internal control system and occupational fraud prevention framework have a tendency to converge in historical development, which become fraud risk management framework.\nIn addition, in view of the fact that both the internal control and the occupational fraud prevention framework originated in the United States, it will be very important to refer to the provisions of United States of America law, especially Insurance Fraud Prevention Model Act, and Model Insurance Fraud Act. Finally, this article will draw some conclusions and give some advice on the basis of fraud risk management framework and United States of America law, expecting to promote the formation of an anti-fraud environment in the overall insurance industry.