Hiring similar-looking cancer patients as substitutes to defraud critical illness compensation involving 26 million insurance policies throughout China and Hong Kong

As the epidemic slowed, the insurance market gradually recovered, but the accompanying corruption complaints showed signs of rebound.

The Independent Commission Against Corruption has received 32 complaints in the first nine months of this year, which is a drop from 24 in the entire year of last year. This is forcing an average of more than 40 complaints a year in the past five years.

The ICAC smashed two insurance-related corruption and fraud syndicates last month. One of them was a false claim for critical illness insurance. After the insurance agent purchased critical illness insurance with an annual premium of up to 280,000 yuan for the insured, the other cancer disease was used. The patient’s medical records were scammed by the insurance company for 9 million yuan in compensation.

The insurance agent involved in the case then repeated its tricks at least three times and obtained cancer medical certificates from medical institutions in Hong Kong and the Mainland. The total amount of compensation fraudulently obtained by the four insurance policies amounted to 26 million yuan. So far, four people, including insurance agents, have been arrested. The case is still under investigation, and more people may be arrested.

Further reading:

Last month, the ICAC smashed a group-operated critical illness insurance false claim involving as much as 26 million yuan. The case occurred between 2017 and 2020 and involved 4 insurance policies, two of which were purchased by Hong Kong residents and the other two. The insured persons in this group are mainlanders from Guangdong Province.

In the case with the highest claim amount, the compensation amounted to 9 million yuan. Chen Jialiang, Chief Investigation Officer of the Enforcement Office, stated that the insurance agent in the case purchased a high-indemnity critical illness insurance for the insured, with an annual premium of 280,000 yuan. After the 12 to 18-month "cooling-off period", through the intermediary, patients with lymphoma who are similar in appearance and age to the insured person will be searched for in the medical center or hospital with the insured person’s ID card and accompanied by an insurance agent. Have a physical examination and take samples for testing to obtain a certificate of lymphoma to defraud the insurance company.

After receiving the complaint, the ICAC launched an investigation and found that the insurance agent involved in the case made about 2 million yuan in bribes, while the insured, intermediary and patient received between tens of thousands to millions of yuan in remuneration. The ICAC Four people have been arrested.

After further investigation, they revealed that the same insurance agent did the same thing and purchased one or more critical illness insurances for themselves and other group members, with an annual premium ranging from 80,000 to 120,000 yuan, and then arranged for cancer diseases in the Mainland. Patients went to mainland hospitals or medical institutions for physical examinations to obtain certificates of nasopharyngeal cancer and breast cancer to defraud relevant Hong Kong insurance companies. The relevant policyholders subsequently received a total of about 17 million in compensation, and insurance agents collected about 2.5 million in bribes.

The Chief Investigation Officer of the Executive Office Zhang Jiabao said frankly that in the three subsequent cases that were uncovered, the persons involved have not been arrested. Two of them were from the Mainland. They used to travel between China and Hong Kong from time to time. However, due to the epidemic, customs clearance has been indefinite, which has greatly increased their activities in Hong Kong. Reduce, increase the difficulty of law enforcement.

As for how this "through-train" criminal process was exposed?

Zhang Jiabao added that due to the huge amount of compensation involved, the claim was made during the first one or two years of the policy. Therefore, the insurance company requires the policyholder to also go to the doctor appointed by the company for review. However, when the insured meets with the doctor, I can’t tell you, whether the condition of the cancer patient in question, or even the medical record he had received, he said," the incident was eventually revealed.

Zhang Jiabao reminded that the staff of medical institutions and laboratories should pay more attention to confirming the patient's identity before the patient's consultation and physical examination, especially for insurance claims. He also emphasized that the ICAC will continue to maintain close contact with the insurance industry and regulatory agencies. , To combat corruption with a "three-pronged" approach.

The ICAC charged six foremen and workers involved in the illegal rebate of 70,000 yuan in the collection of illegal commissions from the ICAC. The Director of the Social Relations Office of the ICAC to host a meeting on integrity leadership of public institutions: a corruption case is enough to destroy credibility

01News