Claims Auditing in Automobile Insurance: Fraud Detection and Deterrence Objectives

Research on insurer management of opportunism in claiming has developed in two parallel literatures. One is a theoretical literature on insurance contracting that yields predictions about the nature of optimal auditing strategies for the deterrence of fraud. The other is a literature based upon statistical analysis of claims that yields empirical strategies for the detection of fraudulent claims. This article links the two literatures by providing an empirical assessment of insurers’ auditing practices in relation to theoretical predictions. The analysis makes use of a data set on the disposition of more than 1,000 randomly selected automobile personal injury protection claims settled in the state of Massachusetts. The findings of the article are consistent with the use of rational auditing strategies by insurers and with the use of audits for both deterrence and detection.     

Detection of Automobile Insurance Fraud With Discrete Choice Models and Misclassified Claims

The insurance industry is concerned with the detection of fraudulent behavior. The number of automobile claims involving some kind of suspicious circumstance is high and has become a subject of major interest for companies. This article demonstrates the performance of binary choice models for fraud detection and implements models for misclassification in the response variable. A database from the Spanish insurance market that contains honest and fraudulent claims is used. The estimation of the probability of omission provides an estimate of the percentage of fraudulent claims that are not detected by the logistic regression model.     

Insurance Fraud

Insurance fraud is a major problem in the United States at the beginning of the 21st century. It has no doubt existed wherever insurance policies are written, taking different forms to suit the economic time and coverage available. From the advent of “railway spine” in the 19th century to “trip and falls” and “whiplash” in the 20th century, individuals and groups have always been willing and able to file bogus claims. The term fraud carries the connotation that the activity is illegal with prosecution and sanctions as the threatened outcomes. The reality of current discourse is a much more expanded notion of fraud that covers many unnecessary, unwanted, and opportunistic manipulations of the system that fall short of criminal behavior. Those may be better suited to civil adjudicators or legislative reformers. This survey describes the range of these moral hazards arising from asymmetric information, especially in claiming behavior, and the steps taken to model the process and enhance detection and deterrence of fraud in its widest sense. The fundamental problem for insurers coping with both fraud and systemic abuse is to devise a mechanism that efficiently sorts claims into categories that require the acquisition of additional information at a cost. The five articles published in this issue of the Journal of Risk and Insurance advance our knowledge on several fronts. Measurement, detection, and deterrence of fraud are advanced through statistical models, intelligent technologies are applied to informative databases to provide for efficient claim sorts, and strategic analysis is applied to property‐liability and health insurance situations.     

金融消费者权益保护:全国首例醉酒交通肇事保险赔偿案

醉酒交通肇事保险公司免赔似成惯例,反射出我国金融消费者在权益保护方面的弱势地位和认识误区。近期济南两级法院做出的全国首例醉酒驾驶交通肇事判决保险公司赔付案,彰显了金融司法监管的威力,并为如何创新监管体系以维护金融消费者权益,促进金融交易公平化提供了理念上的启示。     

Centralizing Insurance Fraud Investigation

The study of insurance fraud and its remedy is a hot topic of research, mainly because the problem of insurance fraud is so widespread. In the United States many state governments have setup agencies to combat fraud. These Insurance Fraud Bureaus (IFB) are typically established to gather information about potential fraudulent claims, and to advise prosecuting officers on the nature of each offense. This paper presents the conditions under which more fraud will be observed in an economy where an IFB conducts all audits than in an economy where each insurance company is responsible for its own investigation. Even if fraud increases, policyholders may be better off than in economy lacking an IFB. One unambiguous case where policyholders are always better is when the IFB conducts every investigation at a cost that is equal to the industry's average.     

互联网保险投保风险分析——基于消费者权益保护角度

我国互联网保险发展迅速,却少有文献从消费者权益保护角度出发分析互联网保险投保过程中存在的风险。为此,课题组通过创新三种不同投保实践的调研方式,调研互联网保险投保过程中存在的风险。发现互联网保险投保过程中存在条款说明义务履行不到位、网页宣传与保障内容不符、投保人和被保险人的身份无法确定、未成年人死亡保险金额问题、客服服务不专业、互联网保险合同成立生效时间的争议风险、消费者信息安全缺乏保障等问题,对此,可从完善相关法律法规、完善投保流程操作、加强创新、提高互联网保险客服的专业素质、完善互联网保险监管制度等方面来加强互联网保险投保过程中的消费者权益保护。     

消费者投诉冲击与保险公司业绩北大核心

保险消费者权益保护是保险监管的目标之一,也是保险市场健康发展与成熟的标志。本文以中国保险监管部门开通首个保险消费者投诉热线作为外生政策变量,利用2009-2018年中国163家保险公司数据设计准自然实验,研究了保险消费者投诉热线的外部监督职能及其对保险公司业绩的影响。研究结果表明:保险消费者投诉热线的开通显著降低了消费者权益保护水平更差的保险公司业绩;佣金激励水平越高,保险消费者投诉冲击对消费权益保护水平更差的保险公司业绩的负向影响越显著;区分人身保险公司与财产保险公司后发现,保险消费者投诉冲击对消费者权益保护水平更差的财产保险公司业绩的负向影响更显著。本文研究成果丰富了消费者权益与保险公司治理理论,对保险消费者权益保护实践和保险市场高质量发展具有启示意义。     

巨灾失踪保险理赔问题

伴随巨灾的频发,巨灾失踪人员的保险理赔问题已成为保险业亟待解决的课题。巨灾失踪人员的保险理赔面临哪些困境,保险业应作何反思,并该如何应对。本文结合相关法律规定及保险契约约定,对上述问题进行分析,并提出对策。     

Fraud Risk in Emerging Markets

David L. Stulb, joint leader of Ernst ＆ Young＇s global Fraud Investigations ＆ Dispute Servicespractice, said,“Major fraud and corruption scandals attract headlines around the world, dramatically affecting corporate and market values. With the fear of fraud greatest in emerging markets, and with 20% of all companies having been victims of fraud, the consequences for those companies that continue to underestimate the risk could be severe.” at the launch of the 9th Global Fraud Survey, Fraud Risk in Emerging Markets.     

Insurance Guaranty Schemes in a Contingent Claims Setting

The introduction of an insurance guaranty scheme can have significant influence on the pricing and capital structures in a competitive market. This contribution summarizes the major findings of a working paper written by Schmeiser and Wagner (Working Papers on Risk Management and Insurance (IVW-HSG), No. 80, 2010). The effect on competitive equity-premium combinations is studied while considering a framework with policyholders and equity holders where guaranty fund charges are volume-based, as levied in existing schemes. Several settings with regard to the origin of the fund contributions are assessed and the immediate effects on the incentives of the policyholders and equity holders are analyzed through a one-period contingent claim approach. One result is that introducing a guaranty scheme in a market with competitive conditions entails a shift of equity capital towards minimum solvency requirements. Hence adverse incentives may arise with regard to the overall security level of the industry.     

Assessing the Risk Potential of Premium Payment Options in Participating Life Insurance Contracts

Most life insurance contracts embed the right to stop premium payments during the term of the contract (paid-up option). Thereby, the contract is not terminated but continues with reduced benefits and often provides the right to resume premium payments later, thus increasing the previously reduced benefits (resumption option). In our analysis, we start with a basic contract with two standard options, namely, an interest rate guarantee and annual surplus participation. Next, in addition to the features of the basic contract, a paid-up and resumption option is included in the framework. The valuation process is not based on assumptions about a particular policyholders' exercise strategy but instead assesses the risk potential from the insurer's viewpoint by providing an upper bound for any possible exercise behavior. This approach provides important information to the insurer about the potential hazard of offering the paid-up and resumption option. Further, the approach allows an analysis of the impact of guaranteed interest rate, annual surplus participation, and investment volatility on the values of the premium payment options.     

The Impact of Insurance Fraud Detection Systems

This article analyzes the impact of detection systems in an insurance fraud context. In a noncommitment Costly State Verification setting insurers can only detect fraudulent claims by performing costly audits, and policyholders are overcompensated by the optimal insurance contract. We show that auditing becomes more effective and overcompensation can be reduced, when insurers are able to condition their audits on the information provided by detection systems.     

Selection Bias and Auditing Policies for Insurance Claims

Selection bias results from a discrepancy between the range of estimation of a statistical model and its range of application. This is the case for fraud risk models, which are estimated on audited claims but applied on incoming claims in the design of auditing strategies. Now audited claims are a minority within the parent sample since they are chosen after a severe selection performed by claims adjusters. This article presents a statistical approach that counteracts selection bias without using a random auditing strategy. A two‐equation model on audit and fraud (a bivariate probit model with censoring) is estimated on a sample of claims where the experts are left free to take the audit decision. The expected overestimation of fraud risk derived from a single‐equation model is corrected. Results are close to those obtained with a random auditing strategy, at the expense of some instability with respect to the regression components set. Then we compare auditing policies derived from the different approaches.     

Bagging集成方法在保险欺诈识别中的应用研究

保险欺诈不仅危及保险公司的正常经营,增加投保人的负担,甚至有可能影响到国家的金融稳定。随着大数据时代的到来,保险反欺诈亟需引入革命性技术。Bagging集成方法以其可调节模型结构、易于部署、参数空间可控、支持并行运算等特点成为保险公司进行保险反欺诈一个好的选择。Bagging方法主要包括Bagging算法、Random Subspace算法、Random Patches算法,它们又能与不同基学习器结合构成新的分支算法及算法特例。本文基于这些算法对保险欺诈问题进行了实证检验,分析了各算法及与基学习器的适用性问题,以及基学习器个数对算法表现的影响。分析发现:针对保险欺诈识别问题,在Bagging、Random Subspace、Random Patches三者之中,Random Patches算法的表现最好,Bagging的运行时间最短;不同算法适用的基学习器不同,但总体来说最适合Bagging集成方法的是决策树;基于决策树的方法都一致选择是否委托律师代理作为最重要的特征;基学习器个数对不同Bagging算法表现的影响并不一致。     

保险消费者权利保护体系探析

在理论界仍然对是否存在“金融消费者”概念等基本问题争执不下的时候,2013年10月26新消法通过.这次法律修订,捅破了最后一层窗户纸,金融消费者保护体系构建迫在眉睫.本文探讨四个相互关联的问题：保险服务对象是“保险消费者”还是“保险投资者”,消费者权益保护法能否简单适用于保险行业,现有保险消费者保护法律体系存在什么问题,以及如何完善保险消费者权益保护体系.     

The Role of Repetition and Observability in Deterring Insurance Fraud

In this paper, I analyze an inspection game between an insurer and an infinite sequence of policyholders, who can try to misrepresent relevant information in order to obtain coverage or lower insurance premium. Because claim-auditing is costly for the insurer, ex-post moral hazard problem arises. I find that the repeated game effect serves as a commitment device, allowing the insurer to deter fraud completely (for sufficiently high discount rate) but only when the policyholders observe past auditing strategies. Under weaker observability conditions, only partial efficiency gains are generally possible. I conclude that the insurers should spend resources on signaling their anti-fraud attempts to the potential policyholders. Similar conclusions can be drawn with respect to conceptually similar problems, such as tax evasion.     

保险诈骗的成因、类型与防范

随着保险业的迅猛发展,保险诈骗案件也日渐增多。保险欺诈不仅给保险业造成巨额经济损失,损害了诚实投保人的利益．而且严重扰乱保险市场秩序,破坏了社会的稳定。应采取积极的防范措施,通过提高员工的综合素质、建立重大赔案调查制度、实现伤者医疗跟踪服务和实行保险行业信息共享等方式,减少保险骗赔案件的发生。