• 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.

• Journal of Internet of Things and Convergence
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• v.8 no.2
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• pp.13-24
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• 2022

In order to explore the context of fraudulent claims and the measures for preventing them targeting the long-term care institutions for the elderly, which is increasing every year in Korea, this study conducted the text mining analysis using the media report articles. The media report articles were collected from the news big data analysis system called 'BIG KINDS' for about 15 years from July 2008 when the Long-Term Care Insurance for the Elderly took effect, to February 28^th 2022. During this period of time, total 2,627 articles were collected under keywords like 'elderly care+fraudulent claims' and 'long-term care+fraudulent claims', and among them, total 946 articles were selected after excluding overlapped articles. In the results of the text mining analysis in this study, first, the top 10 keywords mentioned in the highest frequency in every section(July 1^st 2008-February 28^th 2022) were shown in the order of long-term care institution for the elderly, fraudulent claims, National Health Insurance Service, Long-Term Care Insurance for the Elderly, long-term care benefits(expenses), elderly care facilities, The Ministry of Health & Welfare, the elderly, report, and reward(payment). Second, in the results of the N-gram analysis, they were shown in the order of long-term care benefits(expenses) and fraudulent claims, fraudulent claims and long-care institution for the elderly, falsehood and fraudulent claims, report and reward(payment), and long-term care institution for the elderly and report. Third, the analysis of TF-IDF was similar to the results of the frequency analysis while the rankings of report, reward(payment), and increase moved up. Based on such results of the analysis above, this study presented the future direction for the prevention of fraudulent claims of long-term care institutions for the elderly.

• 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.

• 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.

• 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.

• THE INTERNATIONAL COMMERCE & LAW REVIEW
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• v.69
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• pp.407-426
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• 2016

The Marine Insurance Act 1906 (MIA 1906) has been a successful piece of legislation, having rarely been amended and having established, or served as an influence in the development of, the basis of marine insurance legislation in several countries. However, it has been recognised that some parts of the MIA 1906 have begun to show their antiquated nature, especially where established principles which were once thought to reflect undoubted propositions of law are now being openly criticised. Since 2006, the Law Commission and Scottish Law Commission (the 'Law Commissions') have been engaged in a major review of insurance contract law, finally leading to the Insurance Act 2015. The Insurance Act 2015 received Royal Assent on 12 February 2015, and was based primarily on the joint recommendations of the Law Commissions. The 2015 Act made substantial changes to several main areas of marine insurance law & practice: (i) the replacement of the pre-contractual duty of disclosure with a duty to make a "fair presentation of the risk"; (ii) the abolition of the "insurance warranty" under the Marine Insurance Act 1906, s.33, and provision of a new default remedy of suspension of liability until the breach is cured; (iii) partial codification of the fraudulent claims rule in insurance contract law, etc. The Act did not provide for any new statutory duty for insurers to investigate or pay claims in a timely fashion, although this may be revisited in the next Parliament. Moreover, the Law Commissions have reopened their consideration of the doctrine of insurable interest. The 2015Actmay not then signal the end of the legislative programme in this area.

• THE INTERNATIONAL COMMERCE & LAW REVIEW
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• v.47
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• pp.129-156
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• 2010

Since the 1970s, international construction employers have commonly requested first demand guarantees upon their contractors as a form of security for due performance of their works. Contractors prefer the greater protection offered by more traditional forms of security requiring presentation of an arbitral award or other evidence of the caller's entitlement to compensation. Many contractors nonetheless feel that they have no alternative but to provide these unconditional guarantees in order to compete. However, these unconditional first demand guarantees are controversial and have given rise to numerous disputes both in arbitration and litigation. Disputes arising from first demand guarantees can be broken down into a) applications to prevent a perceived fraudulent or otherwise unfair or improper calling of a guarantee, b) claims arising from such abusive calls and c) claims relating to the consequences of such calls even if the call itself may not be abusive as such. The contractors should carefully assess the risk of an abusive call being made bearing in mind the difficulties he may face in seeking to prevent such a call. He should also bear in mind the difficulties, delays and cost he is likely to encounter in seeking to recover any monies wrongfully called. One option would be to provide that the call can only be made once and to the extent that the employer's damages have been assessed or even incurred or even for the default to have been established by an arbitral tribunal or court. Another option would be to provide that any call be accompanied by a decision of a competent and impartial third party stating that the contractor is in breach. For example, such a requirement could be incorporated into a construction contract based on the FIDIC Conditions by submitting this decision to a Dispute Adjudication Board. Another option would be to provide for the "ICC Counter-Guarantee Scheme". In sum, there would appear to be room for compromise between the employer and the contractor in respect of first demand guarantees by conditioning the entitlement to call such guarantees to the determination of a competent and impartial third party.

• 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.