• 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.26 no.1
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• pp.71-78
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• 2016

The value of using health insurance claim database is continuously rising in healthcare research. In studies where comorbidities act as a confounder, comorbidity adjustment holds importance. Yet researchers are faced with a myriad of options without sufficient information on how to appropriately adjust comorbidity. The purpose of this study is to assist in selecting an appropriate index, look back period, and data range for comorbidity adjustment. No consensus has been formed regarding the appropriate index, look back period and data range in comorbidity adjustment. This study recommends the Charlson comorbidity index be selected when predicting the outcome such as mortality, and the Elixhauser's comorbidity measures be selected when analyzing the relations between various comorbidities and outcomes. A longer look back period and inclusion of all diagnoses of both inpatient and outpatient data led to increased prevalence of comorbidities, but contributed little to model performance. Limited data range, such as the inclusion of primary diagnoses only, may complement limitations of the health insurance claim database, but could miss important comorbidities. This study suggests that all diagnoses of both inpatients and outpatients data, excluding rule-out diagnosis, be observed for at least 1 year look back period prior to the index date. The comorbidity index, look back period, and data range must be considered for comorbidity adjustment. To provide better guidance to researchers, follow-up studies should be conducted using the three factors based on specific diseases and surgeries.

• Journal of Oral Medicine and Pain
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• v.30 no.2
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• pp.215-230
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• 2005

The study was intended to investigate how dentists in private dental clinic thought on the present claim and review of dental insurance to reflect it in future establishing dental insurance policies. 1,465 dentists who were running own dental clinic in Pusan Metropolitan City and the south part of Kyungsang province were surveyed in February, 2004. A total of 406 copies of finished questionnaire were finally retrieved and analyzed. The findings are as follows. 1. About insurance claim affairs : Most of the subject of insurance claim was by dentist himself or dental hygienist(nurse). Agency claiming was carried under 20% of total insurance claim. 2. The degree of attendance on insurance lecture : The degree of attendance on insurance lecture was relatively low. 3. Filing a protest against insurance claim : Filing a protest against insurance claim was reavealed about half-and-half for "have been" or "have not been". 4. Private clinic dentist,s opinion about the regulations affecting review of dental insurance : Private clinic dentists opinion about current guide for insurance review of dental fee was“the guidance is difficult and unfair cutback of claim fee may be carried”. 5. The affairs about health insurance review agency : About 70% of private clinic dentists have dissatisfaction on health insurance review agency. 6. Standpoint of private clinic dentists about issuance of receipt for dental fee : About 70% of private clinic dentist have an difficulty in issuance of receipt for dental fee. 7. The affairs about change insurance noncoverage treatment to insurance coverage treatment : Most of private clinic dentists hoped that insurance coverage about full mouth scaling, pit and fissure sealant, fluoride application. But they do not hoped that insurance coverage about geriatric denture, prothodontic treatment except precious metal, photopolymerization resin treatment.

• Journal of Preventive Medicine and Public Health
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• v.39 no.5
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• pp.433-437
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• 2006

Objectives: The aim of this study is to develop a methodology for estimating a nationwide statistic for hernia operations with using the claim database of the Korea Health Insurance Cooperation (KHIC). Methods: According to the insurance claim procedures, the claim database was divided into the electronic data interchange database (EDI_DB) and the sheet database (Paper_DB). Although the EDI_DB has operation and management codes showing the facts and kinds of operations, the Paper_DB doesn't. Using the hernia matched management code in the EDI_DB, the cases of hernia surgery were extracted. For drawing the potential cases from the Paper_DB, which doesn't have the code, the predictive model was developed using the data mining technique called SEMMA. The claim sheets of the cases that showed a predictive probability of an operation over the threshold, as was decided by the ROC curve, were identified in order to get the positive predictive value as an index of usefulness for the predictive model. Results: Of the claim databases in 2004, 14,386 cases had hernia related management codes with using the EDI system. For fitting the models with applying the data mining technique, logistic regression was chosen rather than the neural network method or the decision tree method. From the Paper_DB, 1,019 cases were extracted as potential cases. Direct review of the sheets of the extracted cases showed that the positive predictive value was 95.3%. Conclusions: The results suggested that applying the data mining technique to the claim database in the KHIC for estimating the nationwide surgical statistics would be useful from the aspect of execution and cost-effectiveness.

• Journal of Preventive Medicine and Public Health
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• v.27 no.2 s.46
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• pp.242-257
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• 1994

In Korea, female workforce has reached more than 40% of total working population, but the effects of work on spontaneous abortion are yet to be examined. This study as conducted to investigate the occupational effects on spontaneous abortion. Medical insurance claim data were used to examine the effects of the employment status and industry of employment on spontaneous abortion. The study population was composed of females, aged $15{\sim}44$, who were the beneficiary of medical insurance in the month of June, 1993. The working females covered by medical insurance for industrial workers, had the highest age-adjusted Spontaneous Abortion rate (SAB rate=claim frequency of spontaneous abortion/claim frequency of complication of pregnancy, childbirth and the puerperium), 6.65% whereas female dependants of medical insurance for industrial workers had the lowest age-adjusted SAB rate, 4.54%. Among industrial workers, the workers in manufacturing industry had the highest age-adjusted Spontaneous Abortion ratio(SAB ratio=claim frequency of spontaneous abortion/claim frequency of completly normal delivery), 43.2/100 whereas those in financing and service industry had age-adjusted SAB ratio, 16.2/100 and 20.5/100, respectively. The results of the study suggest the adverse effect of manufacturing Industry on reproduction. Work environments such as chemical exposures, overwork, awkard posture, and job stress should be further studied for their effects on reproductive functions of female.

• Journal of the Korean Data and Information Science Society
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• v.16 no.4
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• pp.1147-1157
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• 2005

Bonus-Malus system is generally constructed based on claim frequency and Bayesian credibility model is used to represent claim frequency distribution. However, there is a problem with traditionally used credibility model for the purpose of constructing bonus-malus system. In traditional Bonus-Malus system adopted credibility model, individual estimates of premium rates for insureds are determined based solely on the total number of claim frequency without considering when those claims occurred. In this paper, a new model which is a modification of structural time series model applicable to counting time series data are suggested. Based on the suggested model relatively higher premium rates are charged to insured with more claim records.

• The Journal of the Korean life insurance medical association
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• v.24
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• pp.43-48
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• 2005

• The Journal of the Korean life insurance medical association
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• v.20
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• pp.28-31
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• 2001