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    Title: 論保險內部詐欺之防治─以保險人之內稽內控為出發點
    The Prevention and Detection of Internal Fraud of Insurer: From the Aspect of Internal Audit and Internal Control
    Authors: 盧郁文
    Lu, Yu-Wen
    Contributors: 張冠群
    盧郁文
    Lu, Yu-Wen
    Keywords: 保險詐欺
    內部控制
    內部稽核
    職業人員詐欺
    詐欺防治
    insurance fraud
    internal control
    internal audit
    occupational fraud
    prevention and detection of fraud
    Date: 2021
    Issue Date: 2021-09-02 16:03:28 (UTC+8)
    Abstract: 保險詐欺一詞，於我國學說上一直以來都廣為討論，然而定義亦多有爭執、眾說紛紜，故本文之首要目標乃參照各相關文獻並界定何謂保險詐欺。而保險制度運作之參與者眾多，不論保險詐欺之施行者為外部抑或內部人員，都將造成保險人財產上與名譽上之損失，將詐欺者之身分預設為保險公司外部人員之見解已逐漸無法應付越來越多變的保險詐欺型態，相較於外部人員之詐欺，內部人員之詐欺手段通常更為複雜，亦不以操縱保險契約之各環節為限，保險人面對內部詐欺之挑戰應如何因應便成了一值得探討的疑問。
    本文將先探討內部控制制度理論之起源與發展歷程，並以之為基礎，由其五要素之核心概念為出發，觀察其如何幫助企業在營運、遵循與匯報方面維持一定水準，再分析內部稽核制度、三道防線理論如何輔助內部控制制度之維持效能與進行分工。又內部詐欺是由保險人內部職業人員所施行之詐欺行為，為求防治措施之完整性，本文進一步嘗試以職業人員詐欺防治之框架所列之程序作為阻斷保險內部詐欺之方法，並觀察出內稽內控制度與職業人員詐欺防治框架，二者於歷史之發展上係有匯流之趨勢，並就匯流後之詐欺風險管理框架歸納出所有必備之防治程序要素。
    鑒於內稽內控制度與職業人員詐欺防治框架皆起源於美國，是本文以其兩部示範法規範為主要參酌對象，即保險詐欺防治示範法與保險詐欺示範法，最後綜合詐欺風險管理框架之理論與美國法之經驗對我國保險業內部控制及稽核制度實施辦法、保險業保險詐欺風險管理工作指引提出改進建議，希望藉此完善我國制度對保險內部詐欺防治之規範，同時促成整體保險業反詐欺環境之形成。
    Although the term insurance fraud has been widely discussed in doctrines, disputes on the definition of insurance fraud still remain. Therefore, the primary goal of this article is to refer to relevant documents and define what insurance fraud is.
    In the process of defining insurance fraud, it is not hard to find that the focus point of doctrines is always put on the external fraud, even though both insider and outsider of the insurer may engage in insurance fraud. Moreover, the means of internal insurance fraud are usually more complicated compared with the external insurance fraud, which is, presupposing the identity of the fraudster as an outsider of the insurance company has gradually been unable to cope with the ever-changing types of insurance fraud. How the insurer should respond to the challenge of internal fraud has become a question worthy of discussion.
    This article will discuss the origin and development of the internal control theory, and based on it, observing how it can help organization to reach the objectives of operation, compliance and reporting with it’s core concept of its five components, and then analyzes how the internal audit and the theory of the three lines of defense assist the effectiveness of the internal control and the assignment of roles and responsibilities.
    Furthermore, due to internal fraud is a fraud committed by the insurer’s staff, this article attempts to use the procedures listed in the prevention and detection of occupational fraud as a method to block internal insurance fraud, and discovers that the internal control system and occupational fraud prevention framework have a tendency to converge in historical development, which become fraud risk management framework.
    In addition, in view of the fact that both the internal control and the occupational fraud prevention framework originated in the United States, it will be very important to refer to the provisions of United States of America law, especially Insurance Fraud Prevention Model Act, and Model Insurance Fraud Act. Finally, this article will draw some conclusions and give some advice on the basis of fraud risk management framework and United States of America law, expecting to promote the formation of an anti-fraud environment in the overall insurance industry.
    Reference: 一 中文文獻
    (一)書籍
    1.甘添貴，體系刑法各論(第二卷)，自刊，2008年。
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    (二)期刊論文
    1.王怡心，原則性的內部控制處理準則，證券暨期貨月刊，第28卷第10期，頁5-15，2010年。
    2.李茂生，刑法新修妨害電腦使用罪章芻議(上)，台灣法學雜誌，第54期，頁235-247，2004年。
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    4.張冠群，台灣保險法關於違反告知或通知義務不退還保險費規定之檢討，法學新論，第26期，頁51-80，2010年。
    5.許恆達，資訊安全的社會信賴與刑法第三五九條的保護法益 ⎯⎯ 評士林地方法院九十九年度訴字第一二二號判決，月旦法學雜誌，第198期，頁233-249，2011年。
    6.陳俊元，論保險詐欺之吹哨者法制─以美國法之經驗為中心，台灣法學雜誌，第208期，頁99-108，2015年。
    7.陳豐年，保險詐欺防制對策: 從保險人角度出發，萬國法律，第183期，頁11-22，2012年。
    8.劉邦繡，立法院第九屆及本屆審議之「揭弊者保護法草案」疑義問題與展望，台灣法學雜誌，第391期，頁61-75，2020年。
    9.謝昱煒，論金融機構特別背信罪，臺大法學論叢，第45卷第4期，頁2031-2092，2016年。

    (三)專書論文
    1.林依仁，規範制定與行政契約，載: 2012行政管制與行政爭訟，中央研究院法律學研究所，頁183-262，2016年。
    2.周愫嫻、張耀中，各國保險詐欺犯罪管制政策之比較研究，載: 刑事政策與犯罪研究論文集(9)，法務部保護司，頁61-80，2006年。

    (四)研討會論文
    施懿純、張綺芫，保險詐欺相關問題之研究，保險金融管理學術暨產學合作研討會，2008年4月。

    (五)學位論文
    1.李昱興，以層級程序分析就保險業經營管理防治保險犯罪之探討─以保險詐欺為例，高苑科技大學經營管理研究所碩士論文，2011年。
    2.林國豐，保險與刑法之交錯─保險詐欺之研究，國立政治大學法學院碩士在職專班碩士論文，2013年。
    3. 柯雅玲，保險詐欺之研究，國立臺灣大學法律學院科際整合法律學研究所碩士論文，2017年。
    4.陳伯滄，論保險詐欺態樣與防治，東吳大學法學院法律學系碩士在職專班法律專業組碩士論文，2018年。
    5.陳致魁，保險詐欺相關法律規範之比較研究，東海大學法律學研究所碩士論文，2015年。
    6.陳鑕靂，保險業內部控制與內部稽核制度監理法治問題之研究─以保險法第148條之3第1項與第171條之1第4項為核心，國立政治大學風險管理與保險學系碩士論文，2016年。
    7.連煥明，論公司治理下內部控制與內部稽核之實現與變革─以金融機構為例，國立政治大學經營管理碩士學程碩士論文，2004年。
    8.黃俊傑，保險詐欺防範機制之研究，世新大學法學院碩士論文，2016年。
    9.游淑觀，財務再保險之內部控制與內部稽核-HIH與AIG案例分析，國立政治大學商學院經營管理碩士學程碩士論文，2006年。
    10.楊憲宗，保險詐欺與逆選擇防阻之研究，國立中正大學法律學系研究所碩士論文，2016年。
    11.趙偉傑，規範制定公私協力之研究─保險業內部控制及稽核監理法制為例，國立政治大學法律學系研究所碩士論文，2013年。
    12.潘穩中，從保險契約法之觀點論保險詐欺之防制，國立臺灣大學法律學研究所碩士論文，2013年。
    13.鄭宏彬，集團保險詐欺犯罪之研究，元智大學管理碩士在職專班碩士論文，2014年。
    14.羅正安，從博達案件探討公司治理、內部控制與內部稽核人員角色之定位，義守大學管理研究所碩士論文，2005年。
    15.羅錫標，論產物保險業之內稽內控─就日月光公司案分析，國立政治大學商學院經營管理碩士學程碩士論文，2007年。

    二 英文文獻
    (一)書籍
    1.Biegelman, M. T., & Bartow, J. T., Executive Roadmap to Fraud Prevention and Internal Control: Creating a Culture of Compliance (2nd ed., 2012).
    2.Box, G. E. P., Hunter, S. J., & Hunter, W. G., Statistics for Experimenters: Design, Innovation, and Discovery (2nd ed., 1978).
    3.Dewey, J., Democracy and Education (DOI:10.5840/cogito19915249., 1916).
    4.Golden, T. W., Skalak, S. L., Clayton, M. M., & Pill, J. S., A Guide to Forensic Accounting Investigation (2nd ed, 2012).
    5.Imai Masaaki., Kaizen (Ky’zen), the Key to Japan’s Competitive Success The Key to Japanese Competitive Success (1st ed.,1986).
    6.Moeller, R. R., COSO Enterprise Risk Management: Understanding the New Integrated ERM Framework (1st ed., 2007).
    7.Shewhart, W. A., Statistical Method from the Viewpoint of Quality Control (1939).
    8.Vona, L. W., Fraud Risk Assessment: Building a Fraud Audit Program (2008).
    9.Wells, J. T., Corporate Fraud Handbook (5th ed., 2017).
    10.Zhao, X., Hwang, B., & Low, S. P., Enterprise Risk Management in International Construction Operations (Softcover reprint of the original 1st ed. 2015 ed., 2016).

    (二)期刊論文
    1.Albrecht, W. S., Albrecht, C. & Albrecht, C. C., Current Trends in Fraud and its Detection, Vol.17 Information Security Journal: A Global Perspective. 2-12 (2008).
    2.Cressey, D. R., The Theory of Differential Association: An introduction, Vol. 8. No.1 Social Problems. 2-6 (1960).
    3.Eisenberg, M.A., Corporate Governance: The Board of Directors and Internal Control. Vol. 19 Cardozo Law Review. 237-264 (1997).
    4.Howe, M. A., & Malgwi, C. A., Playing the Ponies: A $5 Million Embezzlement Case, Vol. 82, No. 1 Journal of Education for Business. 27-33 (2006).
    5.Lakis, V., & Giriūnas, L., The Concept of Internal Control System: Theoretical Aspect. Vol. 91. No.2 Ekonomika, 142-152 (2012).
    6.Langfield-Smith, K., Management Control Systems and Strategy: A Critical Review, Vol. 22. No.2 Accounting, Organizations and Society. 207-232 (1997).
    7.Mackevičius, J., & Giriūnas, L., Transformational Research of the Fraud Triangle. Vol.92. No.4 Ekonomika. 150-163 (2013).
    8.Pietrzak, M., & Paliszkiewicz, J., Framework of Strategic Learning: The PDCA Cycle. Vol. 10. No.2 Management. 149-161 (2015).
    9.Newcombe, C. B., Implied Private Rights of Action: Definition, and Factors to Determine Whether a Private Action Will Be Implied from a Federal Statute, Vol. 49 Loyola University Chicago Law Journal. 117-147 (2017).
    10.Potter, P., & Toburen, M., The 3 Lines of Defense for Risk Management. Vol. 63. No.5 Risk Management. 16-17 (2016).
    11.Abdullahi, R, & Mansor, N., Fraud Triangle Theory and Fraud Diamond Theory: Understanding the Convergent and Divergent For Future Research, Vol. 5, No.4 International Journal of Academic Research in Accounting, Finance and Management Sciences. 38-45 (2015).
    12.Rikio Maruta, Maximizing Knowledge Work Productivity: A Time Constrained and Activity Visualized PDCA Cycle. Vol. 19. No.4 Knowledge and Process Management. 203-214 (2012).
    13.Todd, J.D., Welch, S.T., Welch, O.J., & Holmes, S.A., Insurer vs. Insurance Fraud: Characteristics and Detection, Vol.22. No.2 Journal of Insurance Issues. 103-124 (1999).
    14.Viaene, S., & Dedene, G., Insurance Fraud: Issues and Challenges, Vol. 29. No.2 Geneva Papers on Risk and Insurance - Issues and Practice. 313-333 (2004).
    15.Wolfe, D., & Hermanson, D. R., The Fraud Diamond: Considering Four Elements of Fraud. Vol.74. No.12 The CPA Journal. 38-42 (2004).

    (三)研討會論文
    M oen, R., & Norman, C., Evolution of the PDCA cycle, In Proceedings of the 7th ANQ Congress.

    (四)機構報告
    1.American Institute of Certificated Public Accountants, Internal control: elements of a coordinated system and its importance to management and the independent public accountant, special report, egrove.
    2.American Institute of Certified Public Accountants., Codification of auditing standards and procedures; Statement on auditing standards, 001, egrove.
    3.Association of Certified Fraud Examiners, 1996 Report to the Nation on Occupational Fraud and Abuse, ACFE.
    4.Association of Certified Fraud Examiners, Report to the Nations on Occupational Fraud and Abuse: 2012 Global Fraud Study, ACFE.
    5.Association of Certified Fraud Examiners, Report to the Nations on Occupational Fraud and Abuse: 2016 Global Fraud Study, ACFE.
    6.Association of Certified Fraud Examiners, Report to the Nations on Occupational Fraud and Abuse: 2020 Global Fraud Study, ACFE.
    7.Association of Certified Fraud Examiners et al., Management Antifraud Programs and Controls.
    8.Association of Certified Fraud Examiners, The American Institute of Certified Public Accountants, & The Institute of Internal Auditors, Managing the Business Risk of Fraud: A Practical Guide, AICPA | CIMA Competency and Learning.
    9.Association of Certified Fraud Examiners, & Committee of Sponsoring Organizations of the Treadway Commission, Fraud Risk Management Guide Executive Summary, COSO.
    10.Association of Certified Fraud Examiners, & Grant Thornton, Anti-fraud Playbook: The Best Defense is a Good Offense.
    11.Chartered GIobal of Management Accountant, Fraud Risk Management: A Guide to Good Practice, CGMA.
    12.Chartered Institute of Loss Adjusters, Fraud and property claims.
    13.Chartered Institute of Management Accountants, Fraud risk management: A guide to good practice.
    14.Committee of Sponsoring Organizations of the Treadway Commission. 1992 Internal Control─Integrated Framework, ACADEMIA.
    15.Committee of Sponsoring Organizations of the Treadway Commission, 2012 Internal Control—Integrated Framework.
    16.Committee of Sponsoring Organizations of the Treadway Commission, 2013 Internal Control—Integrated Framework Executive Summary, COSO.
    17.Committee of Sponsoring Organizations of the Treadway Commission, & Institute of Internal Auditors, Leveraging COSO across the Three Lines of Defense, COSO.
    18.Dentons, Re-assessing the Three Lines of Defense (3LoD) model during a time of continued crisis and remote working, Dentons.
    19.International Association of Insurance Supervisors, Application Paper on Deterring, Preventing, Detecting, Reporting and Remedying Fraud in Insurance, IAIS.
    20.International Association of Insurance Supervisors, Insurance Core Principles and Common Framework for the Supervision of Internationally Active Insurance Groups, IAIS.
    21.Insurance Europe, The impact of insurance fraud.
    22.Insurance Europe, Insurance fraud: not a victimless crime.
    23.Insurance Fraud Taskforce, Insurance Fraud Taskforce final report, GOV.UK.
    24.Institute of Internal Auditors, A Research Study Submitted to the Institute of Internal Auditors From The Chicago Chapter.
    25.Institute of Internal Auditors, IIA Position Paper: The Three Lines of Defense in Effective Risk Management and Control, Institute of Internal Auditors Global.
    26.Institute of Internal Auditors, IIA Exposure Document: Three Lines of Defense, Institute of Internal Auditors North America.

    (五)學位論文
    Zimbelman, M. F., Assessing the risk of fraud in audit planning (Doctoral thesis), The University of Arizona.

    三 網路資料
    (一)工商時報數位編輯，詐保！保戶被當盤子 埋單105億理賠金，工商時報，https://ctee.com.tw/news/insurance/388095.html
    (二)鄭慧菁，雪中送炭 壽險啟動住院期間理賠，現代保險新聞網，https://www.rmim.com.tw/news-detail-3960
    (三)Barr-Pulliam, D., Nkansa, P., & Walker, K., From Compliance to Strategy: Using the Three Lines of Defense Model to Evaluate and Motivate Internal Audit Contributions to Accounting Research, SSRN, https://ssrn.com/abstract=2993364
    (四)Brad Appleton, I-SPI: Improvement follows Spiral, http://www.bradapp.com/docs/i-spi/patterns/impr-follows-spiral.html
    (五)Insurance Fraud Bureau Australia, What is Insurance Fraud? Insurance Fraud Bureau Australia, https://ifba.org.au/#what-is-insurance-fraud
    (六)Insurance Information Institute, Facts + Statistics: Fraud, Insurance Information Institute, https://www.iii.org/fact-statistic/facts-and-statistics-insurance-fraud
    (七)National Association of Insurance Commissioners, INSURANCE FRAUD, NAIC, https://content.naic.org/cipr_topics/topic_insurance_fraud.htm
    (八)Sandrine Noël, Insurance fraud Problem definition and overview of approaches across Europe. Paper presented at the 2010 Symposium on XIII International Conference about Insurance Crime, https://piu.org.pl/public/upload/ibrowser/04_Insurance_fraud_S_Noel.pdf
    (九)The Actuary, CEA rebrands as Insurance Europe, The Actuary, https://www.theactuary.com/news/2012/03/2012/03/01/cea-rebrands-insurance-europe
    Description: 碩士
    國立政治大學
    風險管理與保險學系
    107358003
    Source URI: http://thesis.lib.nccu.edu.tw/record/#G0107358003
    Data Type: thesis
    DOI: 10.6814/NCCU202101170
    Appears in Collections:[Department of Risk Management and Insurance] Theses

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