• Journal of Information Technology Services
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• v.6 no.2
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• pp.1-18
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• 2007

Many researches have been done in insurance fraud as the amount and frequency of insurance fraud have been increasing continuously. In particular, the development of insurance fraud detection system using large database management techniques including data mining or link analysis based on visual method have been the main research topic in insurance fraud. However, this kinds of detection system were very ineffective to find unintentional insurance fraud happened by accident even though it was so good to find intentional and organized crime insurance fraud. Therefore, this research suggests insurance fraud as an ethical decision making and applies TPB(Theory of Planned Behavior) for the finding of reasons and prevention strategies of unintentional insurance fraud happened by accident. The results of research show that TPB is very appropriate model to explain the behavior of insurance fraud and that insurance agents force to do insurance fraud as affecting perceived behavior control. Therefore, education and pubic relations for insurance fraud are very effective for preventing insurance fraud and developing insurance service industry.

• Journal of the Korea Society of Computer and Information
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• v.24 no.1
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• pp.207-215
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• 2019

The insurance system is indispensable to our society. However in recent years, there have been a lot of insurance fraud crimes, such as the abuse of these valuable insurance system and the cheating the insurance proceeds. These insurance frauds make the insurance companies harder to manage, and as a result, the insurance premiums have risen, which has caused a lot of damaging good policyholders. However, the damage caused by insurance fraud has been continuously increasing due to the punishment of cotton stick. Therefore, after the long discussion, the 'The Act for Prevention of Insurance Fraud', which is a special law recently has been enacted. However, within two years of the enactment of this law, which was enacted after much anticipation and long waiting, there is already debate about its effectiveness. The reason for this is that even though the law was enacted and enforced, insurance fraud continues to increase and even punishment for these crimes is not strengthened, and now it is time to look for specific problems and resolutions for these crimes see. So in this paper the author dealt with the problems of the law, first, related regulation of insurance payment, second, right to terminate insurance contract and return of insurance proceeds, third, regulation on notification of investigations, fourth, regulations on the adequacy of hospitalization. Of course, since this law has just been enacted, there are many other problems besides these problems, but I tried to present a fresh resolution based on the problems that have been mainly discussed since the legislative period.

• Information Systems Review
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• v.5 no.1
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• pp.49-60
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• 2003

The purpose of this study is to empirically and practically verify the applicability of visualization data mining tool in detecting real-word insurance frauds that are now emerged as one of the most serious problems socially and economically. For the verification, Analyst's Notebook by i2, which has been known as the most effective visualization data mining tool, was adopted. With Analyst's Notebook, fraud-probable insurance transactions from a very large insurance claims are selected and then substantiation for insurance frauds are attempted. The results show that Analyst's Notebook not only detects insurance fraud transactions from a vast number of insurance claims, but is also able to pinpoint organized crime group by associating one fraud transaction to another fraud transaction. Therefore, it is safe to conclude that visualization data mining is very effective in detecting false transactions and crime behaviors including insurance fraud.

• Journal of the Korea Society of Computer and Information
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• v.25 no.3
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• pp.117-127
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• 2020

Recently, proving insurance fraud has become increasingly difficult because it occurs intentionally and secretly via organized and intelligent conspiracy by specialists such as medical personnel, maintenance companies, insurance planners, and insurance subscribers. In the case of car accidents, it is difficult to prove intentions; in particular, an insurance company with no investigation rights has practical limitations in proving the suspicions. This paper aims reveal that the detection of organized and conspired insurance fraud, which had previously been difficult, could be dramatically improved through conspiring insurance fraud detection modeling using social network analysis and visualization of the relation between suspected group entities and by seeking developmental research possibilities of data analysis techniques.

• The Korean Society of Law and Medicine
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• v.14 no.2
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• pp.11-41
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• 2013

Article 347 of criminal law provides the act of deceiving another, thereby taking property or obtaining pecuniary advantage from another. On the other hand, the concepts of fraud and abuse are confused upon interpretation since the definition in National Healthcare Insurance Law is unclear, and it affects closely to the administrative measures such as surcharge levy by the period of inspection, therefore, the disputes continue in the forms of formal objection, administrative ruling and administrative litigation. This study aims to look over the legal problems on application of criminal fraud toward the abuse of 'Paid Medical Expenses(Article 57, Sections 1 and 4 of the National Health Insurance Act)'. The main issues are concept of abuse(Article 57, Sections 1 and 4 of the National Health Insurance Act), the problems of Directions of Health-Welfare Ministry on aspect of 'Nullum crimen sine lege' Principles, the proper sentenc-ing guidelines of fraud.

• Journal of Convergence for Information Technology
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• v.11 no.6
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• pp.270-281
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• 2021

With the development of information technology, the size of insurance fraud is increasing rapidly every year, and the method is being organized and advanced in conspiracy. Although various forms of prediction models are being studied to predict and detect this, insurance-related information is highly sensitive, which poses a high risk of sharing and access and has many legal or technical constraints. In this paper, we propose a machine learning insurance fraud prediction model based on blockchain, one of the most popular technologies with the recent advent of the Fourth Industrial Revolution. We utilize blockchain technology to realize a safe and trusted insurance information sharing system, apply the theory of social relationship analysis for more efficient and accurate fraud prediction, and propose machine learning fraud prediction patterns in four stages. Claims with high probability of fraud have the effect of being detected at a higher prediction rate at an earlier stage, and claims with low probability are applied differentially for post-reference management. The core mechanism of the proposed model has been verified by constructing an Ethereum local network, requiring more sophisticated performance evaluations in the future.

• THE INTERNATIONAL COMMERCE & LAW REVIEW
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• v.67
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• pp.119-142
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• 2015

Many insurers have traditionally incorporated "fraud clauses" into insurance policies, setting out the consequences of making a fraudulent claim. Even in the absence of an express terms, English courts provide insurers with a remedy for a fraudulent claim. However, the law in this area is complex, convoluted and confused. English Law Commission think that the law in this area needs to be reformed for three reasons; (1) the disjunctive between the common law rule and section 17 generates unnecessary disputes and litigation, (2) increasingly, UK commercial law must be justified to an international insurance society, and (3) the rules on fraudulent claims are functioned as a deterrent if they are clear and well-understood. In order for these purposes, English Law Commission recommends a statutory regime to the effect that, when an insured commits fraud in relation to a claim, the insurer should (1) have no liability to pay the fraudulent claim and be able to recover any sums already paid in respect to the claim, and (2) have the option to treat the contract as having been terminated with from the time of the fraudulent act and, if chosen the option, be entitled to refuse all claims arising after the fraud, but (3) remain liable for legitimate losses before the fraudulent act. LC is not recommending a complete restatement of the law on insurance fraud generally. For example, LC does not seek to define fraud, instead, recommends the introduction of targeted provisions to confirm the remedies available to an insurer who discovers a fraud by a policyholder.

• Proceedings of the Korean Society of Computer Information Conference
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• 2017.01a
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• pp.103-104
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• 2017

최근들어 보험사기로 인한 피해가 날로 극심해지고 있다. 이러한 보험사기로 인한 피해를 예방하고 억제하기 위해 오랜시간 논의를 해왔으며, 결국 보험사기방지 특별법을 제정하여 2016. 9. 30. 시행하였다. 그러나 단지 이러한 특별법 시행만으로는 보험사기로 인한 폐해를 완전히 해결할 수 없다. 따라서 특별법 시행으로 인한 현실적인 보험사기 억제효과를 살펴보고 이에 대한 문제점을 분석하여야 한다. 이에 본 연구에서는 보험사기방지 특별법 시행으로 인한 효과에 대하여 현실적으로 살펴보고, 이에 대한 문제점을 모색한 후 개선방안을 제시해 보고자 한다.

• Health Policy and Management
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• v.28 no.2
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• pp.186-193
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• 2018

Background: The aim of our study was to review the findings of health insurance fraud investigations and to evaluate their impacts on medical costs for target and non-target organizations. An interrupted time series study design using generalized estimation equations was used to evaluate changes in cost following fraud investigations. Methods: We used National Health Insurance claims data from 2009 to 2015, which included 20,625 medical institutions (1,614 target organizations and 19,011 non-target organizations). Outcome variable included cost change after fraud investigation. Results: Following the initiation of fraud investigations, we found statistically significant reductions in cost level for target organizations (-1.40%, p<0.001). In addition, a reduction in cost trend change per month was found for both target organizations and non-target organizations after fraud investigation (target organizations, -0.33%; non-target organizations of same region, -0.19%; non-target organizations of other regions, -0.17%). Conclusion: This study suggested that fraud investigations are associated with cost reduction in target organization. We also found similar effects of fraud investigations on health expenditure for non-target organizations located in the same region and in different regions. Our finding suggests that fraud investigations are important in controlling the growth of health expenditure. To maximize the effects of fraud investigation on the growth of health expenditure, more organizations needed to be considered as target organizations.

• Transactions of the Korean Society of Automotive Engineers
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• v.21 no.6
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• pp.58-63
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• 2013

It is very difficult to evaluate the impact speed, who caused the accident and what the injury risk of the vehicle occupants was from the outcome of the accident. That's the main reason why there are so many insurance fraud related to vehicle accident. In this study, a vehicle crash accident suspected to an insurance fraud had been reconstructed to evaluate crash speed and the relationship between the crash accident and passenger injury risk. To do this, the scene was reconstructed based on accident investigation report and three vehicle crash tests were done at 27kph, 37kph and 70kph. The crash speed of 27kph and 37kph were chosen based on the damaged vehicle and 70kph was chosen based on the driver's statement. Based on the damage of vehicle and dummy injury measure, impact speed is estimated around 20 to 30kph and the dummy measures show that the passengers are not seems to be severely injured in this speed range.