• 무역상무연구
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• 제67권
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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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• 제21권9호
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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.

• 무역상무연구
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• 제53권
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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.

• 보건행정학회지
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• 제34권2호
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• pp.163-177
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• 2024

연구배경: 본 연구는 부당청구 예방형 자율점검제 시범사업의 "개선요청 통보 및 모니터링" 중재활동이 의료기관의 중재 실시 전과 후 청구건수와 청구총진료비 청구행태에 있어서의 변화를 검증하고자 하였다. 방법: 자료는 건강보험심사평가원의 2021년 7월부터 2022년 2월까지 시범사업 항목인 '정맥 내 일시주사(KK020)'를 청구한 기관 중 예방형 자율점검제 대상기관으로 선정된 1,129개 의료기관의 청구자료와 신고 현황자료를 활용하였다. 비교 대상을 선정하기 위해 1:3 비율로 성향점수매칭을 사용하였고, 청구행태 변화를 검증하기 위해 대응표본 t-검정과 t-검정을 실시하였다. 또한 청구행태 변화에 차이가 있는 경우 이에 영향을 미치는 요인분석을 위하여 회귀분석을 시행하였다. 결과: 중재 실시 전과 후의 청구행태는 실험군의 모든 의료기관 종별에서 청구건수와 청구총진료비가 유의하게 감소하였고, 의원의 대조군에서는 유의한 증가를 보였다. 의료기관 및 의사 특성에 따른 중재 실시 전·후 청구행태는 실험군은 의원의 의사 연령 40세 미만을 제외하고 모든 종별에서 유의하게 감소하였다. 대조군은 종합병원과 병원은 개원기간에서, 의원은 표시과목에서 일부 유의한 감소가 있었고, 의사 50세 이상 남성에서 유의하게 증가한 것으로 나타났다. 실험군 대상 의료기관의 청구행태에 변화에 대한 회귀분석 결과, 모든 종별에서 중재 실시 전과 후에 청구건수와 청구총진료비가 유의하게 감소하였다. 또한 의료기관과 의사 특성에서 병원은 개원기간이 길수록 유의한 증가를 나타났고, 의원은 소재지역과 표시과목(기타)에서 유의한 감소를 보였다. 결론: 실험군의 부당청구 예방형 자율점검제의 중재 실시 이후 청구경향의 변화가 연구가설대로 감소하는 경향을 보였다. 이는 제도 시행 직후에 의료기관 스스로 청구행태를 개선하고, 교정하는 사전예방적 활동의 효과가 존재하는 것으로 나타났다. 또한 대조군에서도 통보 대상기관 위주의 제도운영방식에도 불구하고 일부 유의한 감소가 나타난 것은 예방형 자율점검제의 간접적인 효과로 볼 수 있다. 따라서 비대상기관에도 청구행태 개선활동이 이루어질 수 있도록 적극적인 홍보와 교육, 간담회 등의 추가적인 지원과 지속적인 모니터링이 필요하다. 이를 통해 부당청구가 감소될 수 있도록 예방형 자율점검제를 확대하는 것이 바람직하다.

• 한국중재학회지:중재연구
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• 제24권2호
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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.

• 무역상무연구
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• 제36권
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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.

• 무역상무연구
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• 제33권
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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.

• 의료법학
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• 제8권1호
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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.

• 한국중재학회지:중재연구
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• 제22권3호
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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.

• 무역상무연구
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• 제69권
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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.