保險詐欺之黑數難以計數，除了道德性風險之形成外，且對保險公司之經營形成偌大變數，同時更由於保險詐欺之得逞，以致於保費必須提高，最終轉嫁到大多數善良而安份的保戶。其間商業醫療保險之詐欺，概多以理賠金額低而又次數頻繁的方式進行，近年來隨著犯罪詐騙之風高漲，更是有朝向集團化與專業化的趨勢。筆者以一介資深的保險理賠人員的實務經驗，結合自己的所學，以文獻分析法以及深度參與法為研究方法，對我國目前之商業醫療保險的保險詐欺行為，由實務面進行歸納整理，並提出本研究之成果有三項：1.醫療保險詐欺未必事先規劃，卻可能臨時起意； 2.醫療保險詐欺其間醫療院所扮演著關鍵的角色；3.防範醫療保險詐欺，必須深入當事人之生活。此外，筆者亦由專業理賠人員之視角，提出於理賠程序中所當改進之處，以供有關單位參考。 It is difficult to count the dark figure of insurance fraud. The formation of moral hazards is highly variable for the operation of insurance companies. Should insurance fraud succeed, the insurance premiums would also increase, which is ultimately distributed amongst non-offending policyholders. Therein, commercial health insurance frauds are mostly low in claim amount but occur frequently. With the recent rise in fraud, there is now a trend towards fraud syndicates and specializations. The author has integrated their own knowledge with the practical experience of a senior medical claims officer, and made use of literature analysis and deep participation for their research method. Taiwan’s current commercial health insurance fraud is collated here and there are three proposed outcomes from this study：1. Medicare fraud are not necessarily planned in advance, rather it might occur unpremeditated.2. Medical institutions play a key role in medicare fraud.3. To prevent medicare fraud, one needs to have a deep understanding of the client’s life.Additionally, the author has proposed ways to improve the claim process from the point of view of a professional insurance claims handler, and this may be used as a point of reference by related units.
