我國保險詐欺已到了相當嚴重的情況，除了透過住院醫療行為而不斷發生的詐騙住院醫療保險，甚至連帶影響到全民健康保險，同時也陸續造成多起重大刑事案件，對於社會風氣與社會觀感都造成相當不良的影響，如果保險詐欺的行為無法被遏止，將對我國經濟與社會造成嚴重的影響。 本研究透過收集各類型的保險詐欺案件，結合統計數據進行資料分析，以找出保險詐欺之特性、行為特徵、與犯罪手法。同時也透過保險專家們的實務意見、各研究文獻與各國保險詐欺防制作法之比較與探討，以共同尋求保險業未來如何面對保險詐欺之適切方法。 本次研究分別就人身保險公司、主管機關與中央健康保險局提出未來作業的建議，期待能對我國保險詐欺防制有所幫助。 壹、對保險公司的建議 一、落實新契約核保風險控管 二、增強核保、理賠人員專業知識 三、建立業務品質管理與業務同仁管理兩大機制機制 四、增加設計保險商品的妥適性 貳、對主管機關的建議 一、針對保險詐欺單獨立法 二、成立專門法庭或檢警部門 三、修改相關保險法令 四、賦予保險公司調查權力 五、強化保險犯罪防制中心（IAFI）功能 参、對中央健康保險局的建議 一、增加與商業保險公司之間的資訊分享 二、加強內部控制與查核 Abstract: Deceptions of medical insurance claim on medical treatments have caused severe problems for the insurance industry and the social welfare system of National Health Insurance. Criminal cases triggered by insurance frauds also have negative influences on the public and the society. If problems of fraud claims of the like cannot be controlled, the society and economics will be facing with more strikes. By collecting a variety of insurance fraud cases and analyzing statistic data, this thesis expects to reveal characteristics of insurance fraud, behavior patterns, and criminal behaviors. By interviewing insurance specialists, this thesis also conducts a comparative study with reference to foreign cases in prevention or reduction of insurance frauds. In such, instruments are provided here to deal with insurance fraud cases in Taiwan in the near future. This study intends to provide life insurance enterprises, competent authorities, and National Health Insurance respectively with suggestions against insurance frauds. Three fields of suggestions are listed as follows: 1 Suggestions to Insurance Enterprises: 1.1 Control new business underwriting 1.2 Enhance professional knowledge of claim specialists and underwriters 1.3 Establish business quality and agency management 1.4 Evaluate insurance product property 2 Suggestions to Competent Authorities: 2.1 Promulgate and enact laws for insurance fraud 2.2 Establish special courts and investigation bureaus for insurance fraud 2.3 Amend related insurance regulations 2.4 Grant investigation power to insurance enterprises 2.5 Reinforce functionality of The Insurance Anti-fraud Institute (IAFI) 3 Suggestions to the Bureau of National Health Insurance 3.1 Enhance the information sharing system with insurance enterprises 3.2 Enhance internal control and audit functions
