醫療保險目的是在填補被保險人因意外或疾病住院時，藉由商業保險的保險金給付，得到基本社會保險保障以外無法支付的費用，然而，近幾年來由於經濟不景氣，醫療保險卻成為犯罪詐欺工具之一，實有必要針對現行醫療保險詐欺防制論述。 本研究內容主要在探討，醫療保險詐欺防制上之困難及所面臨之問題分析，以實際案例的呈現，論述問題嚴重性並提出未來改進方式，以期對於醫療保險詐欺防制有所助益。其探討內容如下： 一 、醫療體系面臨之問題 (一)病歷制度對醫療保險詐欺之探討 (二)全民健康保險申報制度之探討 (三)住院不實及住院浮濫之爭議性 (四)不良醫療院所問題 二、被保險人、集團之問題 三、保險公司之管理分析 四、監理制度之分析 五、司法機關判決分析 由於醫療保險詐欺防制具高度專業性，各種層面所面臨之問題均不相同，惟有各個層面改善自我本身問題後加以整合，始可減少詐欺情形，達到犯罪防制目的，進而提升被保險人醫療品質。 The purpose of health insurance claim is to indemnify loss from hospitalizing because of accident or illness and get compensation when the hospitalization expense may beyond social insurance claim. However, health insurance has become a tool of fraud crime due to the economic depression recently, so that this study is aimed to expound a prevention system on health insurance fraud. In this study, we mainly focus on an actual insurance fraud case to present its seriousness and problems for giving contributions to develop a wholesome health insurance prevention system. The contents are: 1.Medical System Problems Anamnesis versus health insurance fraud National health insurance declaration The controversy of fraudulent and excessive hospitalization Inferior quality hospital and clinic 2.Problems of insured and criminal group 3.Insurance company management analysis 4.Supervise system analysis 5.Judiciary verdict analysis The various components of health insurance fraud prevention system need highly professional proficiency. Only when those components modify their own problems by themselves, the whole system should be facilitated to decrease health insurance fraud and then to promote the insured’s medical quality.
