Take the case to the risk
01 The gist of the case
Falsification of false claim materials, suspected of insurance fraud.
02 Case Introduction
In 2022, an insurance company found during a routine audit that Mr. X, an employee of a company, had obvious claims fraud from 2018 to 2021, such as inconsistencies between diagnosis and treatment and clinical reality, inconsistency between his condition and actual situation, contradictions in medical records, and abnormalities in medical history materials, and defrauded a total of 440,000 yuan. Since the amount involved in the case of Mr. X has reached the sentencing standard, the insurance company reserves the right to report the case to the criminal investigation and recover the compensation from Mr. X.
03 Case Analysis
In this case, if the insured conceals its true situation and submits false materials when making a claim, and there is a false claim, according to Article 27 of the Insurance Law, if the policyholder, the insured or the beneficiary fabricates a false cause of the accident or exaggerates the extent of the loss by means of forged or altered relevant certificates, materials or other evidence, the insurer shall not be liable for compensation or payment of insurance money for the part falsely reported. Where the policyholder, the insured, or the beneficiary commits any of the acts provided for in the preceding three paragraphs, causing the insurer to pay insurance money or expenses, it shall be refunded or compensated.
1) The policyholder deliberately fabricates the subject matter of insurance and defrauds the insurance money;
2) The policyholder, the insured or the beneficiary fabricates false reasons for the occurrence of the insured accident or exaggerates the extent of the loss, and defrauds the insurance money;
3) The policyholder, the insured or the beneficiary fabricates an insurance accident that has not occurred and defrauds the insurance money;
4) The insured or the insured deliberately causes property damage in an insured accident and defrauds the insurance money;
5) The policyholder or beneficiary intentionally causes the death, disability or illness of the insured and defrauds the insurance money.
04 Case Enlightenment
When applying for insurance claims, consumers should follow the principle of good faith, truthfully and fully inform the actual situation, provide true claim information, and do not falsify false claim information to defraud insurance money, so as to avoid illegal and criminal acts.