• 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.

• International Journal of Computer Science & Network Security
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• v.21 no.9
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• pp.125-131
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• 2021

Detecting fraudulent insurance claims is difficult due to small and unbalanced data. Some research has been carried out to better cope with various types of fraudulent claims. Nowadays, technology for detecting fraudulent insurance claims has been increasingly utilized in insurance and technology fields, thanks to the use of artificial intelligence (AI) methods in addition to traditional statistical detection and rule-based methods. This study obtained meaningful results for a fraudulent insurance claim detection model based on machine learning (ML) and deep learning (DL) technologies, using fraudulent insurance claim data from previous research. In our search for a method to enhance the detection of fraudulent insurance claims, we investigated the reinforcement learning (RL) method. We examined how we could apply the RL method to the detection of fraudulent insurance claims. There are limited previous cases of applying the RL method. Thus, we first had to define the RL essential elements based on previous research on detecting anomalies. We applied the deep Q-network (DQN) and double deep Q-network (DDQN) in the learning fraudulent insurance claim detection model. By doing so, we confirmed that our model demonstrated better performance than previous machine learning models.

• THE INTERNATIONAL COMMERCE & LAW REVIEW
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• v.53
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• pp.207-229
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• 2012

In IP 7 and LCCP 201, Law Commission considers the insured's duty of good faith after the formation of the contract. This article intends to review and analyse the legal implications of proposals in IP 7 and LCCP 201. The results of analysis are following. First, Law Commission propose to end the remedy of avoidance under MIA 1906 section 17, because avoidance of past claims is unprincipled, impractical and unnecessarily harsh. Secondly, LC proposes that an insured who makes a fraudulent claim should forfeit the whole claim which the fraud relates, but that the fraud should not invalidate previous and legitimate claims. Thirdly, LC proposes to introduce a statutory right for the insurer to claim damages for the reasonable, foreseeable costs of investigate a fraudulent claim in specific circumstances and that damages would be limited to those cases where the insurer can show an actual, net loss. Finally, LC provisionally propose that an express fraud clause should be upheld in business insurance, whereas in consumer insurance, any term which purports to give the insurer greater rights in relation to fraudulent claims that those set out in statute would be of no effect.

• Health Policy and Management
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• v.34 no.2
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• pp.163-177
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• 2024

Background: This study aims to examine changes in fraudulent claim counts and total reimbursements before and after enhancements in counterfeit claim controls and monitoring of provider claim patterns under the "Proactive self-audit pilot program of fraudulent claims." Methods: This study used the claims data and hospital information (July 2021-February 2022) of the Health Insurance Review and Assessment Service. The data was collected from 1,129 hospitals assigned to the pilot program, selected from the providers who filed a claim for reimbursement for intravenous injections. Paired and independent t-tests, along with regression analysis, were utilized to analyze changing patterns and factors influencing claim behaviors. Results: This program led to a reduction in the number of fraudulent claims and the total amount of reimbursements across all levels of hospitals in the experimental groups (except for physicians below 40 years old). In the control group, general hospitals and hospitals demonstrated some significant decreases based on the duration since opening, while clinics showed significant reductions in specified subjects. Additionally, a notable increase was observed among male physicians over the age of 50 years. Overall, claims and reimbursements significantly declined after the intervention. Furthermore, a positive correlation was found between hospital opening duration and claim numbers, suggesting longer-established hospitals were more likely to file claims. Conclusion: The results indicate that the pilot program successfully encouraged providers to autonomously minimize fraudulent claims. Therefore, it is advised to extend further support, including promotional activities, training, seminars, and continuous monitoring, to nonparticipating hospitals to facilitate independent improvements in their claim practices.

• Journal of Arbitration Studies
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• v.24 no.2
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• pp.109-136
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• 2014

The separability of an arbitration clause is generally recognized throughout the world, but there are no provisions of it under the Federal Arbitration Act(FAA) of the United States. As such, the controversy over the recognition of separability has developed with the rise of certain cases. The Supreme Court recognized this separability based on section 4 of the FAA in the decision of the Prima Paint case. The Court ruled that courts must decide the claim about the fraudulent inducement of an arbitration agreement itself, but they must not decide the claim about the fraudulent inducement of a contract involving a broad arbitration clause, and they have to proceed with the arbitration. The Court said that the subject of an arbitral award is set by the agreement of the parties, and thereby arbitrators can decide the issues about the fraudulent inducement of a contract on the basis of the arbitration clause when it is broad to the point of including the issues. Many courts have extended the separability beyond the fraud context to include other defenses to contract formation in the federal courts such as the occurrence of mistake, illegality, and frustration of purpose. In interpreting the parties' intention of ensuring arbitrator competence, the Supreme Court has treated differently the issues about whether the arbitration agreement exists or not and the issues about whether the preconditions for dispute resolution by a valid arbitration agreement is fulfilled or not. The Court holds that the federal policy in favor of arbitration does not apply to the former issues, and arbitrators can decide theses issues only when parties assign them clearly and unmistakably to them. However, the later issues receive a presumption in favor of arbitration; i.e., when the interpretation of a valid arbitration clause is contested, the arbitrators can decide these issues. In the First Options case, the former issue was questioned. The question of the separability of an arbitration clause is where the validity of the main contract involving the arbitration clause is contested. Therefore, the doctrine of separability did not operate in the First Options case in which the validity of the arbitration clause itself was questioned, and the decision in the First Options was irrelevant to the separability. I think that the Prima Paint case and the First Options case have different issues, and there is no tension between them.

• THE INTERNATIONAL COMMERCE & LAW REVIEW
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• v.36
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• pp.29-46
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• 2007

The fraud exception rule allows for the issuing bank to dishonor the claim if it the documents and transactions bear fraud though the documents presented are complied with the terms and conditions of the letter of credit. A question arises whether the fraud exception rule can apply to innocent beneficiary when fraud is made by 3rd party. United City Merchants v. Royal Bank of Canada showed a good example how to handle in case of innocent beneficiary. At this case House of Lord found that innocent beneficiary deserves payment applying nullity exception rule. I believe that the nullity exception rule is employed for the benefit of innocent beneficiary as far as the issuer and applicant get no actual damage by the 3rd party's fraudulent action which is shown on documents.

• THE INTERNATIONAL COMMERCE & LAW REVIEW
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• v.33
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• pp.191-219
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• 2007

Section 39(5) of Marine Insurance Act 1906 concerns the case where with the privity of the assured, the ship is sent to sea in an unseaworthy state. The underwriters argue that the assured had"blind-eye knowledge" of the particular respect in which the ship was unseaworthy. Blind-eye knowledge requires a conscious reason for blinding the eye. There must be at least a suspicion of a truth about which one do not want to know and which one refuse to investigate. What has caused greater difficulty is the broad provision in s.17 which appears to be unlimited in its scope. The expression "utmost good faith" appears to derive from the idea of uberrimae fidei, words which indeed appear in the sidenote. The concept of uberrima fides does not appear to have derived from civil law and it has been regarded as unnecessary in civilian systems. S.17 raises many questions. But only two of them are critical to the decision of the present appeal-the fraudulent claim question and the litigation question. It is however necessary to discuss them in the context of a consideration of the problematic character of s.17. In the Star Sea Case, for the defendants to succeed in their defence under this part of the case the defendants have to show that claim was made fraudulently. They have failed to obtain a finding of fraud. It is not enough that until part of the way through the trial the owners failed to disclose to the defendants would have wished to see in order to provide them with some, albeit inadequate, evidential support for their alleged defence under s.39(5). The defence under s.17 fails. The Purpose of this work is to analyze the Star Sea Case, and to explore problems of the MIA relating to the judgement of this case.

• The Korean Society of Law and Medicine
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• v.8 no.1
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• pp.137-177
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• 2007

The medical expenses review system in Korea has developed under fee-for-service system with its own unique structure. The importance of reviewing medical expenses has been emphasized, as the size of medical expenditures moving through the health insurance legal context and its weight in the national economy have increased very rapidly. It is, however, analyzed that the feuds and arguments continue among the stakeholders for the lack of laws supporting the medical expenses review system. The medical expenses review is a series of administrative procedures, deciding whether claims from medical care institutions to the insurer are legal and valid or not. It mainly controls the increase of unnecessarily excessive health insurance claim and prevents fraudulent claim and abuse and checks the less use or unsuitable use of medical resources. It also works a function guarantees medical benefits for the appropriate treatment according to the object of health insurance system as a social insurance scheme. The dispute on legal base of the medical expenses review is about the source of law in the medical expenses review. There are the Health Insurance Act and administrative laws as jus scriptum and the guidelines of review as administrative orders. The medical expenses review should reflect various factors, such as the development of medical healthcare technologies, the health expenditures distribution, the financial situation of the health insurance, and the evaluation on the level of appropriate benefits. It is also likely to adapt to the traits of characters of medicine, and trends and transition, Besides it should judge the legality and the validity of medical benefits expenditures by synthesizing these all factors. And the evaluation system of appropriateness of medical benefits was administrative procedure which was consecutive with reviewing the medical expenses system and it was intended to make up for the result of reviewing the medical expenses in more comprehensive levels.

• Journal of Arbitration Studies
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• v.22 no.3
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• pp.119-139
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• 2012

In the case of Banque Paribas V. Banco Santander in England for the reimbursement request of deferred payment credit by the nominated bank, the L/C-issuing bank refused to pay the proceeds at maturity because of a fraudulent transaction. The reason of refusal was that the nominated bank, Banco Santander, had no right of payment in deferred credit before its maturity if it made payment of proceeds without notice to the issuing bank, that is, payment not based upon a credit transaction but on its own account. However, in the case of ADIB V. Fortis Bank in America, the New York court made the decision that the deferred payment bank could not refuse to reimburse to the nominated bank, Fortis Bank, because of fraud. Its decision was based on the UCP600. We have analyzed and investigated the above two cases-one was an English court's decision and the other an American's. The English court's decision was made under UCP500, but the American court's was made under UCP600, which was revised in 2007. As a result, we can expect that from now on in deferred payment credit transactions, the power of the nominated bank will be greater than before, but the issuing bank will bear the risk of the beneficiary's fraud, so the issuing bank will be hesitant to issue deferred payment credit. Notwithstanding, we thought that the New York court decision would come into effect in the activation of deferred payment credit in practical trade transactions.

• THE INTERNATIONAL COMMERCE & LAW REVIEW
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• v.69
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• pp.261-301
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• 2016

Recently the abusive calls on on-demand bonds have been a critical issue among many engineering and construction companies in Korea. On-demand bond is referred to as an independent guarantee in the sense that the guarantee is independent from its underlying contract although it was issued based on such underlying contract. For this reason, the issuing bank is not required to and/or entitled to look into whether there really is a breach of underlying contract in relation to the call on demand-bonds. Due to this kind of principle of independence, the applicant has to run the risk of the on demand bond being called by the beneficiary without due grounds. Only where the call proves to be fraudulent or abusive in a very clear way, the issuing bank would not be obligated to pay the bond proceeds for the call on on-demand bonds. In order to prevent the issuing bank from paying the proceeds under the on-demand bond, the applicant usually files with its competent court an application for injunction prohibiting the beneficiary from calling against the issuing bank. However, it is in practice difficult for the applicant to prove the beneficiary's call on the bond to be fraudulent since the courts in almost all the jurisdictions of advanced countries require very strict and objective evidences such as the documents which were signed by the owner (beneficiary) or any other third party like the engineer. There is another way of preventing the beneficiary from calling on the bond, which is often utilized especially in the United Kingdom or Western European countries such as Germany. Based upon the underlying contract, the contractor which is at the same time the applicant of on-demand bond requests the court to order the owner (the beneficiary) not to call on the bond. In this case, there apparently seems to be no reason why the court should apply the strict fraud rule to determine whether to grant an injunction in that the underlying legal relationship was created based on a construction contract rather than a bond. However, in most jurisdictions except for United Kingdom and Singapore, the court also applies the strict fraud rule on the ground that the parties promised to make the on-demand bond issued under the construction contract. This kind of injunction is highly unlikely to be utilized on the international level because it is very difficult in normal situations to establish the international jurisdiction towards the beneficiary which will be usually located outside the jurisdiction of the relevant court. This kind of injunction ordering the owner not to call on the bond can be rendered by the arbitrator as well even though the arbitrator has no coercive power for the owner to follow it. Normally there would be no arbitral tribunal existing at the time of the bond being called. In this case, the emergency arbitrator which most of the international arbitration rules such as ICC, LCIA and SIAC, etc. adopt can be utilized. Finally, the contractor can block the issuing bank from paying the bond proceeds by way of a provisional attachment in case where it also has rights to claim some unpaid interim payments or damages. This is the preservative measure under civil law system, which the lawyers from common law system are not familiar with. As explained in this article, it is very difficult to block the issuing bank from paying in response to the bond call by the beneficiary even if the call has no valid ground under the underlying construction contract. Therefore, it is necessary for the applicants who are normally engineering and construction companies to be prudent to make on-demand bonds issued. They need to take into account the creditability of the project owner as well as trustworthiness of the judiciary system of the country where the owner is domiciled.