民事欺诈与刑事诈骗的类型化区分

刑事诈骗是民事欺诈中的严重部分,两者最主要的区别在于行为人主观上是否具有非法占有目的。刑事诈骗的行为类型多样,具体构造也存在一定差异,非法占有目的的认定应结合诈骗行为的具体构造展开。交易型诈骗中,作为交易对价的基础事实是否存在对于非法占有目的认定具有决定意义。使用型诈骗的场合,应重视对行为人取得财物后的用途和资金走向的考察,以确定非法占有目的是否成立。财物用途和资金走向无法查清的案件,不能简单地认为属于事实不清、证据不足。资格型诈骗中,非法占有目的的认定应同时考虑行为人是否具有特定资格以及财物的具体用途。民事欺诈与刑事诈骗的区分还要注意欺诈事实是否属于核心或者主要事实以及欺诈程度等。     

Fraud Classification Using Principal Component Analysis of RIDITs

This article introduces to the statistical and insurance literature a mathematical technique for an a priori classification of objects when no training sample exists for which the exact correct group membership is known. The article also provides an example of the empirical application of the methodology to fraud detection for bodily injury claims in automobile insurance. With this technique, principal component analysis of RIDIT scores (PRIDIT), an insurance fraud detector can reduce uncertainty and increase the chances of targeting the appropriate claims so that an organization will be more likely to allocate investigative resources efficiently to uncover insurance fraud. In addition, other (exogenous) empirical models can be validated relative to the PRIDIT‐derived weights for optimal ranking of fraud/nonfraud claims and/or profiling. The technique at once gives measures of the individual fraud indicator variables’ worth and a measure of individual claim file suspicion level for the entire claim file that can be used to cogently direct further fraud investigation resources. Moreover, the technique does so at a lower cost than utilizing human insurance investigators, or insurance adjusters, but with similar outcomes. More generally, this technique is applicable to other commonly encountered managerial settings in which a large number of assignment decisions are made subjectively based on ‘‘clues,‘’ which may change dramatically over time. This article explores the application of these techniques to injury insurance claims for automobile bodily injury in detail.     

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.     

Moral intensity,moral awareness and ethical predispositions: The case of insurance fraud

The issue of insurance fraud by consumers continues to perplex insurance firms, costing billions of dollars per year in the United States alone. Some analysts report that 10 per cent or more of property/casualty insurance claims are fraudulent, while less than 20 per cent of fraudulent claims being detected. Consumer attitudes are becoming more tolerant of insurance fraud in recent years. Recognizing that not all insurance fraud situations are created equal, we investigate variability in perceptions of moral intensity in dissimilar insurance padding situations in a 2 (to help others versus to profit self) × 2 (a small credit union versus a large online insurer) model and compared the results between two independent samples (college students/Millennials and an older adult population). We also investigated the impact of ethical predispositions (formalism and utilitarianism) on moral awareness and moral judgment using these four scenarios. The results suggest that the Millennials may exhibit more situationalism and more lenient judgments of collaborative versus unilateral ethical violations. In particular, ‘for self’ versus ‘for others’ comparisons show striking differences between the two age groups. The results add to the growing literature in explaining intra-personal variability in moral decision making.     

Erklärungsansätze für vertragswidriges Verhalten Versicherungsnehmern aus Sicht der ökonomischen Theorie

The two main purposes of this paper are an introduction to the economic analysis of insurance fraud and furthermore a derivation of factors that determine fraudulent behavior of policyholders on insurance markets. Consequently, we analyze the strategic decision problems of insurance companies and the policyholders and identify some factors that can help to reduce fraudulent behavior. In this context we evaluate two derived starting points for the combat against insurance fraud: fraud detection systems and a consequent charge policy of detected defrauders. We illustrate that both points can help to reduce the cost of fraud. Furthermore, we enhance our earlier analysis with respect to the empirical fact that some individuals care about fairness or — in the insurance fraud context — the legitimacy of their actions. Surprisingly, in some market situations these concerns of some policyholders do not lead to a lower fraud probability. Finally, we discuss how and to what extent insurance companies can influence such ethical concerns of policyholders. On that score, we distinguish insurance specific and insurance unspecific factors and their impact on the consumers attitudes towards insurance fraud.     

基于BP神经网络的保险欺诈识别研究——以中国机动车保险索赔为例

当前保险欺诈在国内外呈现蔓延态势,尤其体现在机动车保险领域,欺诈识别已成为保险欺诈研究的核心内容.目前保险欺诈识别有统计回归和神经网络两大类方法,这两种方法在指导思想和识别流程上各有优缺.本文基于我国财产保险公司车险索赔样本数据,检验BP神经网络在我国保险欺诈识别中的有效性;同时为了尝试统计回归和神经网络的有效融合,本...     

金融诈骗罪刑法单独设节的理性思考

现行刑法将金融诈骗罪单独设节作为刑法分则第三章第五节从而与分则第三章第四节破坏金融管理秩序罪形成独立、并列的关系。这种被视为突破刑法立法体例传统的做法引起理论上的争议。肯定金融诈骗罪单独设节的观点从社会危害性、罪刑法定原则、金融诈骗罪罪群以及便利实务适用等四个方面论证了这种做法的合理性,否定说的学者认为金融诈骗罪单独设节具有与立法体例不合、立法思路不一、无单独设节之必要以及与境外刑法立法趋势相悖等缺陷从而不应单独设节。本文从金融诈骗罪主要客体、金融犯罪逻辑体系以及刑事立法传统等方面论证了金融诈骗罪单独设节不具有合理性且一一回应了肯定说所提出的观点。本文认为,金融诈骗罪的主要客体是金融交易秩序,其是金融管理秩序的下位概念,金融诈骗罪应当划入破坏金融管理秩序罪分节之下。     

Providers’ affiliation,insurance and collusion

This paper provides a theoretical analysis of the benefits for an insurance company to develop its own network of service providers when insurance fraud is characterized by collusion between policyholders and providers. In a static framework without collusion, exclusive affiliation of providers allows insurance companies to recover some market power and to lessen competition on the insurance market. This entails a decrease in the insured’s welfare. However, exclusive affiliation of providers may entail a positive effect on customers’ surplus when insurers and providers are engaged in a repeated relationship. In particular, while insurers must cooperate to retaliate against a fraudulent provider under non-exclusive affiliation, no cooperation is needed under exclusive affiliation. In that case, an insurer is indeed able to reduce the profit of a malevolent provider by moving to collusion-proof contracts when collusion is detected, and this threat may act as a deterrent for fraudulent activities. This possibility may supplement an inefficient judicial system: it is thus a second-best optimal anti-fraud policy.     

保险治理与公司违规——董事高管责任保险的治理效应研究

公司治理机制被认为是影响公司违规的重要因素,然而董事高管责任保险作为一种重要的外部治理机制,是否会影响公司违规尚未得到充分研究。本文研究发现董事高管责任保险显著降低公司违规概率,符合监督效应假说。经工具变量法、Heckman两阶段模型和倾向得分匹配法稳健性检验,上述结论依然成立。影响机制分析表明,董事高管责任保险显著降低了公司违规倾向,显著增加了违规后被稽查的概率,并降低了上市公司的第一类代理成本。对董事高管责任保险的监督职能做进一步分析发现:(1)董事高管责任保险对上市公司经营违规和领导人违规的监督效应更为显著,但对信息披露违规的治理作用并不显著;(2)董事高管责任保险发挥的监督职能与股权属性和保险机构股东治理存在替代效应,与外部审计师治理和董事长CEO二职分离存在互补效应;(3)分组检验结果表明,董事高管责任保险对公司违规的监督效应在外部监管环境较差或者公司内部信息透明度较高的情况下更加显著。本文既提供了保险合约通过公司治理渠道影响公司违规的证据,同时也表明保险机构通过董事高管责任保险为中国资本市场提供了一种较为有效的公司外部治理机制。     

现阶段商业银行汽车贷款保证保险问题分析--兼评保监会《关于规范汽车消费贷款保证保险业务有关问题的通知》

保监会《关于规范汽车消费贷款保证保险业务有关问题的通知》在贷款流程、除外责任、索赔顺序、承保期限等方面对银行汽车贷款产生了较大的影响。该《通知》将被保险人(银行)的实质性审查义务作为保证保险合同生效的要件值得商榷,也没有合理、公平地划分保险公司和银行之间的风险。对此,作者认为,商业银行在汽车消费贷款中不能过分依赖保证保险,积极探索汽车贷款风险防范的其他途径,巧妙利用保险公司的先索抗辩权并不包括汽车的其他财产险、偷盗险等险种的有利条件,注意区分汽车贷款诈骗的情况,严防保险公司对诈骗做扩大解释,从而有效防范和化解汽车贷款义务中存在的风险。     

Feasible fraud and auditing probabilities for insurance companies and policyholders

Insurance claims fraud is counted among the major concerns in the insurance industry, the reason being that excess payments due to fraudulent claims account for a large percentage of the total payments each year. We formulate optimization problems from the insurance company as well as the policyholder perspective based on a costly state verification approach. In this setting??while the policyholder observes his losses privately??the insurance company can decide to verify the truthfulness of incoming claims at some cost. We show simulation results illustrating the agreement range which is characterized by all valid fraud and auditing probability combinations both stakeholders are willing to accept. Furthermore, we present the impact of different valid probability combinations on the insurance company??s and the policyholder??s objective quantities and analyze the sensitivity of the agreement range with respect to a relevant input parameter. This contribution summarizes the major findings of a working paper written by Müller et?al. (Working Papers on Risk Management and Insurance (IVW-HSG), No. 92, 2011).     

Die Rolle der Versicherungsvermittler beim Versicherungsbetrug – experimentelle Ergebnisse

The GDV estimates the amount of insurance fraud across Germany to be € 4 billion per year. This work examines, using experimental approach, the role of insurance agents in insurance fraud. This research shows that fraud behavior is not only dependent on economic motives even though these can make financial sense for the agent. Different crime detection rates and reward scenarios do not lead to any significant differences in behavior. If the insurance agent, however, completed an apprenticeship in the insurance sector, then this agent generally has a lower willingness to support the customer when committing insurance fraud. Against this, specifically men (as a research category) and holders of several policies tend to be more susceptible to support customers in insurance fraud.     

Aufdeckung von Versicherungsbetrug bei Kfz-Schäden mit Hilfe des Benford-Tests

The German Insurance Association estimates a yearly amount of damage of € 1.5?bn to German motor vehicle insurance companies because of systematic fraud by insurance holders. It is supposed that about 10% of submitted claim applications contain manipulated data, therefore insurance companies are forced to complete a detailed and cost intensive case-by-case review of each single application. An alternative method to detect fraud in empiric data is the method of digital analysis based on Benford’s law. The Benford method uses a mathematical law of specific logarithmic distribution attributes of first digits. According to this approach, the data of a Benford set confirm with the expected digit distribution, if the data is not manipulated, whereas fraudulent interventions lead to a deviation from Benford’s law. Hence, until now there has not been any investigation whether the Benford method can also be applied on insurance data. The present article analyses a dataset consisting of more than 120,000 damage claim applications to answer this question as well as to identify the impact of specific characteristics on the probability of fraud contained in claim applications, such as the repair of the vehicle in a franchised or an independent workshop, the vehicle brand or the examination by insurance companies experts. Indeed it could be shown that Benford’s Law is only applicable on second digits of insurance data, but delivers very strong results here: All results of the considered characteristics could be verified by plausible arguments. For this reason insurance companies can benefit from making use of the Benford method to identify those claim applications with a high probability of fraud, which should then be reviewed in more detail so that resources can be allocated in a much more cost efficient way.     

Whistleblower laws and corporate fraud: Evidence from the United States

We use data from the United States to assess whether whistleblower laws that protect private employees from retaliation have an impact on corporate fraud. Currently, eighteen states have whistleblower laws that offer such protection. Our analysis indicates that, in these states, a higher awareness of whistleblower laws is associated with a lower state-level conviction rate for corporate fraud. This finding is consistent with the hypothesis that whistleblower laws that cover private employees have a deterrent effect on corporate fraud, and that awareness of the provisions of whistleblower laws plays a key role in determining their effectiveness as a policy tool.     

Employer strategies to combat health care plan fraud

Each year health care fraud drains millions of dollars from employer-sponsored health plans. Historically, employers have taken a rather tolerant view of fraud. As the pressure to manage health plan costs increases, however, many employers are beginning to see the detection and prosecution of fraud as an appropriate part of a cost management program. Fraud in medical insurance covers a wide range of activities in terms of cost and sophistication--from misrepresenting information on a claim, to billing for services never rendered, to falsifying the existence of an entire medical organization. To complicate matters, fraudulent activities can emanate from many, many sources. Perpetrators can include employees, dependents or associates of employees, providers and employees of providers--virtually anyone able to make a claim against a plan. This article addresses actions that employers can take to reduce losses from fraud. The first section suggests policy statements and administrative procedures and guidelines that can be used to discourage employee fraud. Section two addresses the most prevalent form of fraud--provider fraud. To combat provider fraud, employers should set corporate guidelines and should enlist the assistance of employees in identifying fraudulent provider activities. Section three suggests ways to improve fraud detection through the claims payment system--often the first line of defense against fraud. Finally, section four discusses the possibility of civil and criminal remedies and reviews the legal theories under which an increasing number of fraud cases have been prosecuted.     

A Comparison of State-of-the-Art Classification Techniques for Expert Automobile Insurance Claim Fraud Detection

Several state‐of‐the‐art binary classification techniques are experimentally evaluated in the context of expert automobile insurance claim fraud detection. The predictive power of logistic regression, C4.5 decision tree, k‐nearest neighbor, Bayesian learning multilayer perceptron neural network, least‐squares support vector machine, naive Bayes, and tree‐augmented naive Bayes classification is contrasted. For most of these algorithm types, we report on several operationalizations using alternative hyperparameter or design choices. We compare these in terms of mean percentage correctly classified (PCC) and mean area under the receiver operating characteristic (AUROC) curve using a stratified, blocked, ten‐fold cross‐validation experiment. We also contrast algorithm type performance visually by means of the convex hull of the receiver operating characteristic (ROC) curves associated with the alternative operationalizations per algorithm type. The study is based on a data set of 1,399 personal injury protection claims from 1993 accidents collected by the Automobile Insurers Bureau of Massachusetts. To stay as close to real‐life operating conditions as possible, we consider only predictors that are known relatively early in the life of a claim. Furthermore, based on the qualification of each available claim by both a verbal expert assessment of suspicion of fraud and a ten‐point‐scale expert suspicion score, we can compare classification for different target/class encoding schemes. Finally, we also investigate the added value of systematically collecting nonflag predictors for suspicion of fraud modeling purposes. From the observed results, we may state that: (1) independent of the target encoding scheme and the algorithm type, the inclusion of nonflag predictors allows us to significantly boost predictive performance; (2) for all the evaluated scenarios, the performance difference in terms of mean PCC and mean AUROC between many algorithm type operationalizations turns out to be rather small; visual comparison of the algorithm type ROC curve convex hulls also shows limited difference in performance over the range of operating conditions; (3) relatively simple and efficient techniques such as linear logistic regression and linear kernel least‐squares support vector machine classification show excellent overall predictive capabilities, and (smoothed) naive Bayes also performs well; and (4) the C4.5 decision tree operationalization results are rather disappointing; none of the tree operationalizations are capable of attaining mean AUROC performance in line with the best. Visual inspection of the evaluated scenarios reveals that the C4.5 algorithm type ROC curve convex hull is often dominated in large part by most of the other algorithm type hulls.     

For fraud,look under ‘serious and organized crime’

ABSTRACT

The UK government’s response to fraud cannot be disentangled from its broader ‘serious and organized crime’ (SOC) strategy. In order to explore whether fraud should—in public policy, criminal justice and law enforcement terms—be seen primarily as an SOC issue, there is a need to consider questions about whether or not ‘SOC’ is a sensible object of policy-making in the first place. Several arguments in favour of an SOC policy are identified in the paper. However, the notion of an overarching SOC policy is problematic for three reasons. First, SOC is a fundamental misrepresentation of reality, which does not correspond to a real social problem. Second, SOC policy can limit the development of more problem-specific crime strategies, Third, the ‘SOC’ label can negatively transform how social problems are perceived over the long term. If fraud is to be better understood and dealt with, it may therefore be necessary to extract it from its current inclusion within wider SOC strategy.     

Cold,warm, warmer,hot! Locating financial literacy hot spots

One of the key challenges of the financial literacy agenda involves resource allocation decisions. Given competing priorities, an approach to identifying areas of greatest need is required. It is argued that such prioritisation may be determined by assessing vulnerability, referred to as ‘hot spots’ of vulnerability. This article examines the specific vulnerability ‘hot spot’ of financial fraud. Vulnerability is defined as those areas that have experienced comparatively greater concentration of financial fraud cases. Drawing on criminological theory, in particular aspects of the operational practice of ‘hot spots’ policing, a framework for resource allocation decision making within the financial literacy context is presented. Analogous with hot spots policing, concentration of resources to ‘known’ areas of vulnerability is likely to result in more impactful financial literacy outcomes.     

金融诈骗犯罪的新型特征与定罪模式的思考

本文根据近年来我国金融诈骗犯罪的新型特征,结合我国金融诈骗罪的定罪模式特点,对其中的缺陷进行了分析,并提出了改进的建议。     

Versicherungsbetrug aus vertragstheoretischer Sicht

Insurance fraud is a significant economic problem. Following the deregulation of the German insurance market in 1994, contractual features are now possible which were previously restricted. Therefore, there is a need to analyse the insurance fraud reduction potential of this instrument. This paper investigates three forms of insurance fraud: ?Costly State Verification“, ? Costly State Falsification“ and third party fraud. Consequences for the optimal contractual design are deduced.