A Study on the Short-term Claim Rates of Medical Insurance

[[abstract]]隨著所得的提高，教育程度及知識水準的提升，保險的觀念也逐漸被大眾所接受，更多人選擇以保險來做為理賠規劃及風險的轉移。近年來，社會結構的改變，人口老化及少子化的情形日趨嚴重，醫療保險已是個人或家庭風險管理所不可或缺。台灣壽險市場競爭激烈，理賠服務的快速、品質及滿意度，會影響保險公司的競爭力，也是影響社會大眾選擇保險公司的重要因素。近年來，保險金給付卻屢遭有心人操作，以致保險詐欺案件層出不窮，衝擊各家壽險公司財務數據，更造成社會資源浪費。 本研究以契約投保年度三年以下保戶的理賠案件為樣本，運用A公司於2010年1月至2013年6月加保已發生醫療險出險保戶共341筆資料作為研究對象，分析人壽保險短期醫療理賠率的影響因素。 分析結果顯示，首期保費繳法非年繳或在投保時告知有投保同業的保戶，其平均理賠率較高。另首期保費繳法非年繳，在身故受益人指定為法定繼承人或投保時告知有投保同業，在身故受益人指定為法定繼承人的保戶，其平均理賠率較高。在理賠率高低兩組預測分析中，投保短期內發生理賠的保戶有年輕化之趨勢，年齡愈輕發生高理賠率機率愈高;投保時身故受益人指定為法定繼承人的保戶發生高理賠率的機率愈高。 本研究結果可提供壽險公司核保的危險選擇及理賠風險管理之參考，對於高風險保戶特徵嚴加審核，期能防止道德危險，杜?不當的理賠。[[abstract]]Along with the increase of incomes, the raise of educational level and general knowledge, the concept of insurance has been gradually accepted by the public, and there are more and more people choosing insurances as claim planning and risk transfer. In recent years, the change of society’s structure, the aging population and the low birth rate are serious issues; therefore, the medical insurance is indispensable either for individuals or for families risk management. The life insurance market in Taiwan is extremely competitive. The efficiency, quality and satisfaction of claim services normally represent an insurance company’s competitiveness, and they are also the important factors for the public to opt an ideal insurance firm. Under the prevalence of utilitarianism, the insurance claim is used by schemers as a tool, and the frequent cases of insurance fraud, which cause a grave impact on every life insurance company’s financial number and even a waste of social resources, have been appearing in recent years. This study analyzes the samples of claim cases filed by the insurance policy holders who have already been insured for or less than three years. There are a total of 341 cases, who had added a medical insurance and later filed a claim, collected between January, 2010 and June, 2013 from A company as a object of a study. Based on these cases, the possible factors of the short-term claim rates of medical insurance are determined. As indicated by the analysis, the claim rates of insurance policy holders (the insured), who pay the initial premium by non-yearly basis or are told that there are other companies providing the same service, are higher than the average. Besides, the claim rates of insurance policy holders (the insured), who pay the initial premium by non-yearly basis and designate the legal heir as the beneficiary of death benefit or are told that there are other companies providing the same service, are also higher than the average. The prediction analyses employed in the groups of high claim and low claim rates exhibit that the number of young insurance policy holders, who make a claim in a short insured period, is increasing; the probability of insurance policy holders, who designate the legal heir as the beneficiary of death benefit, is highest among high claim rates group. The result of this study can serve as a reference for life insurance companies to conduct the risk selection of underwriting practices and risk management of claims. As a result, the potentially risky insureds should be under strict scrutiny so as to prevent moral hazard and preclude improper claims