A Study on Risk Anti-Selection for health care fraud in life insurance

[[abstract]]人壽保險契約乃是依最大誠信原則所訂立。在人壽保險經營組織中，有兩個重要部門，我們常把核保部門比喻成保險公司的第一道防線，理賠部門比喻成保險公司的最後一道防線。核保與理賠人員如何使風險降至最低，並與展業部門並行不悖，實為一門重要課題。 在實務上核保人員如何判別被保險人是否有故意隱匿，或為不實之說明，尤其若被保險人故意隱匿實際狀況，實難判別，故就實證資料加以分析，並探討其相關變數是否均顯著相關，並探討現今國內外關於被保險人告知義務之相關規定，及探討日後應如何消弭此種情形，實為本篇最大研究目的。 本研究由A人壽保險公司自民國90年至92年所承保之保單中，選取被保險人在投保二年內因有違反保險法第六十四條告知義務之事實，經保險公司解除契約並未予理賠給付，或公司逕予保戶達成和解並解除契約者，由保險公司解除契約者為研究對象，其中包含被保險人投保二年內死亡，且有違反保險法告知義務之事實公司解除契約或公司逕予和解者。採用EXCELL輸入原始資料，將資料轉換後，以SPSS進行統計分析。 所選定變數有被保險人之性別、投保年齡、身高、體重、職業類別、體檢別、是否為標準體、要被保險人關係、及婚姻狀況、居住地區、壽險保險金額、醫療日額等，探討其與劣質件之關係，以驗證在核保實務上之判斷，並作為日後核保人員參考之依據。實證結果發現各項變數與劣質件之間有顯著相關。 結論對保險公司之建議如下﹕ 1.要保書告知內容之格式，應妥為修改。2.加強業務人員教育訓練與管理。3.建立理賠分級給付制度。4.兼顧巿場行銷與核保審核制度。5.建立完整通報機制。 期能提供壽險業者，擬訂經營策略之參考，在要保書告知內容亦能提供後續研究者更深入研究，如期能對於壽險公司之穩健經營發展之目標有所助益。[[abstract]]Life insurance contract is made according to the utmost principle. In life insurance management orginazation, having two important departments. We usually regard underwriting department as the first defence of the insurance company, and regard claim department as the last defence. Underwriters and insurance adjusters how to reduce the risk to the lowest, and not against the development department is very important. In practice, underwriter how to judge insured is purposely hide, or is fraud. If insured with intend to hide actually fact, it is difficult to judge. According to empirical data, discussing whether the data are connected with the result is defferent from forerign countries the rule of insureds’anti-declaration obligation in our country. How to decrease this condition is the most important purpose. This study use data from A insurance company are focused on the rescission of contract case due to anti-declaration obligation after two years of policy effect. It is selected six hundred rescission of new business contracts contracts during the time interval between Jan., 2001 and Dec., 2003. Relying on the data collected from Taiwanese insured establishments , multivariate tests and regression analysis results of the study found that, eleven variable factors which have appearent influence on the amount of claim：age of insured , sex of insured, marriage of insured, occupation of insured, medical expense plan , operation expense plan , amount of insured , insured period and area and so on. It comes to the conclusions that： 1. Build up policy’s obligation style. 2. Full of education effect. 3.Take some different grades of payment. 4. Adjust suitable marketing strategy. 5.Build up completed notification system