Take the case to the risk
01 The gist of the case
It is illegal to provide false materials to claim claims and defraud insurance.
02 Case Introduction
In September 2022, Mr. Chan purchased a one-year Ping An Shun Xin Protector. Coverage covers accidental injuries and accidental medical liabilities. In May 2023, the insured, Mr. Chen, had 2 outpatient visits** due to headaches, and the total expenses incurred were about 1,400 yuan. In order to obtain accidental compensation, the outpatient medical records provided to the insurance company were recorded as "accidentally hit the back of the head, there was a hematoma, and brain oscillation was not ruled out". During the audit, the insurance company found that the expense items did not meet the requirements, and after investigation, it was found that Mr. Chen was actually outpatient due to cerebral infarction, hypertension and other diseases**, and the company refused to pay and blacklisted Mr. Chen.
03 Case Analysis
Ping An Shun Xin Bao is a one-year accident insurance product and does not assume sickness insurance liability. Mr. Chen, on the other hand, was suspected of insurance fraud by amending his medical records to have traumatic records and traumatic diagnoses in order to achieve the purpose of compensation.
04 Tips
Paragraph 1 of Article 27 of the Insurance Law of the People's Republic of China stipulates that if the insured or beneficiary falsely claims that an insured accident has occurred and makes a claim or request for insurance money from the insurer without the occurrence of an insured accident, the insurer has the right to terminate the insurance contract and not refund the insurance premium. If a relatively large amount of insurance money is actually obtained by using such fraudulent acts to falsely claim that an insured accident has occurred, it constitutes the crime of insurance fraud.