한국어

기재

미국의 모델보험사기법은 민간기구인 보험사기방지협회(Coalition Against Insurance Fraud, CAIF)가 마련했다.

모델법은 연방법이나 주 법으로 바녕되길 희망하면서 관련 분야의 전문가들이 모여서 만드는 법률안이다.


Model Insurance Fraud Act

(Adopted March 2, 1995; amended September 20, 1995)


Section 1. Definitions


This section defines terms used in the legislation, including "insurance transaction" and "insurer." The term "insurer" includes anyone purported to be in the business of insurance as well as those authorized to do business in that state.


The bill also defines "practitioner" as any individual who is, or is required to be, a licensee of the state and whose services are compensated in whole or part by insurance proceeds. This includes medical providers, lawyers, agents, building contractors, adjusters and automotive repair shops.


These definitions are written to cover all forms of insurance fraud, as discussed above, as well as those who are most likely to commit fraud, and are designed to establish greater consistency from state to state.


Section 2. Fraudulent Insurance Act


A fraudulent insurance act is defined as an act committed by anyone who, knowingly and with intent, defrauds another person for gain. A fraudulent act includes claims fraud, application fraud and the legislation has a separate provision dealing with insurer fraud. Individuals who conspire, aid and/or abet a fraudulent act also are covered by the definition. A conviction under these provisions must meet the criminal burden of proof beyond a reasonable doubt.


Among the actions that fall under the fraudulent act is the preparation and presentation of false information affecting:


• the application for any insurance policy;

• an insurance claim pursuant to any policy;

• any payments made pursuant to any insurance policy.


The actions that would fall under the insurer fraud elements of the fraudulent act include:


• the solicitation for sale of any policy or purported policy;

• an application for certificate of authority;

• misrepresentation of the financial condition of any insurer.


This section makes all forms of insurance fraud, as well as attempts to commit fraud, a specific crime. Without definite language targeting attempts, conspiracies, and aiding or abetting fraud, an insurer often must pay false claims before a crime can be said to be committed; even then, others involved in the fraud may go free. The provision protects consumers from unscrupulous operators by expanding the definition of fraud to include schemes perpetrated by insurers or those who claim to be in the insurance business.


Section 3. Unlawful Insurance Act


An unlawful insurance act is defined as an act committed by anyone who commits or allows to be committed an act with "an intent to induce reliance." Unlike the fraudulent insurance act, "intent to defraud" is not required; the act utilizes a form of recklessness standards. Convictions under this section must meet the civil standard of proof, which requires a preponderance of evidence.


The legislation separates the definition for unlawful insurance actions affecting claims and applications fraud from fraud committed by insurers. Actions falling under the claims/applications fraud portion of the unlawful act include:


• the application for any insurance policy;

• an insurance claim pursuant to any policy;

• payments made in accordance with the terms of any policy.


Actions falling under the insurer fraud portion of the unlawful act include:


• an application for certificate of authority;

• misrepresentation of the financial condition of an insurer;

• the solicitation for sale of any policy or purported policy.


This section expands the legal definition of insurance fraud into an entirely new arena. Those who have shielded themselves from the actual act of fraud-signing a false claim form, for example-can be charged through a civil action, which requires a different standard of proof. This provision is designed to punish individuals who create a fraudulent scheme, such as a medical mill, but have underlings execute it as the schemers reap the bulk of the illegal reward. Like the provisions against fraudulent acts, this section also protects consumers from unscrupulous operators by expanding the definition of fraud.


Section 4. Criminal Penalties


The criminal penalties only apply to those persons charged with committing a fraudulent insurance act. The penalties use a stepladder approach and increase based on the amount defrauded and/or previous convictions for fraud. The provisions are meant to dovetail with the existing penalties already in place in the states for other similar crimes. The penalties would allow the courts and the prosecution to segregate or aggregate the economic loss suffered by the persons defrauded. The highest felony charge includes those charged with committing a fraudulent insurance act where the offense places anyone at risk of death or serious bodily injury.


Criminal sanctions must be severe enough to act as a deterrent rather than be treated by perpetrators as part of the cost of doing the business of fraud. The commonly used stepladder approach deters repeat offenders as well as particularly egregious forms of fraud; states are left free to define those levels as the legislature sees fit.


여정현의 국회법안발의 300건