降低风险，防止保险业欺诈

proactive measuresto mitigate risk and Introduction Dealing with fraud is nothing new for insurers:traditional tactics such as making false claims orproviding incorrect information have long been majorchallenges in a sector where the potential rewardsfor criminals are high. Today, however, the stakesare even higher, with ever-more sophisticated,novel frauds being perpetuated by digital means,amplifying the risk and making detection even fraud detection systems is more important thanever before — and more than ever these rely onaccurate data and smart tech tools to spot red This e-book is designed to help guide insurersthrough this landscape, looking at the key issuesthey face and discussing potential solutions.It provides an overview of the current regulatory At the same time, regulatory requirements oninsurers are intensifying and evolving, and insurersmust comply with an array of different rules indifferent jurisdictions where they operate. While Navigatinga complex U.S. insurers are subject to an intricate nexus ofregulation, with rules imposed at both federal andstate level, and dependent on the type of productsbeing offered. Knowing what rules they are subjectto, and where, is vital to implement a fit-for-purposecompliance program which protects insurers’ To ensure a consistent approach based onbest practice, state regulators come under thebanner of the National Association of Insurance Commissioners (NAIC), which sets standardsand provides guidance. This includes creatingmodel lawson risks such as data security and Under the McCarran-Ferguson Act, each of the50 states has the power to implement their ownrules on insurers. For instance, some (but not all)states require insurance companies to implement However, implementation across jurisdictionscan be patchy. For example, since the NAIC’sInsurance Data Security Model Lawwaspublished in 2017, fewer than half of U.S. At a federal level, all insurance companies, nomatter what state(s) they operate in, must complywith the U.S. Treasury Department’s Office of ForeignAssets Control (OFAC)’s sanctions rules — notablythe requirement to screen potential customers toensure they are not specially designated nationals At a product level, requirements under the BankSecrecy Act and Anti-Money Laundering (AML)rules may also come into play, with providers of Across the board, all insurers must ensurethe brokers/dealers they work with can legallysell their insurance products. This means thatinsurers need to conduct due diligence on theirbrokers to understand who they are dealing with Although OFAC publishes searchable lists of SDNs,results are not necessarily conclusive, and insurersoften need to do further digging to get a ‘hit’. Thiscan be challenging, particularly for smaller regional Key challenges facing Complying with a complex regulatory frameworkis a major challenge facing insurers — but it’s just While some of the risks insurers are grappling withare universal, each line of business also faces its $74.7billion In recent years, the insurance market has becomemore competitive, asnew, disruptiveplayers haveenteredthe market. At the same time, companieshave become increasingly focused on cost control, Life insurers are typically worst affected in termsof the sheer scale of the value of fraud, with theCAIF putting theannual costat $74.7 billionannually2. It’s clear that money laundering poses akey risk to life insurers and their customers, thanks annual cost of fraudaccording to the CAIF Since the Covid-19 pandemic, there has alsobeen a reduction in numbers of investigatorsworking ‘in the field’, resulting in much more desk-based work, with investigators increasingly using Common frauds such as lying on applications,forging policy changes, or fake deaths, are todayjoined by new tactics such as identity theft and Property and casualty fraud is another prime candidate for criminal activity, withthe cost estimated at $45 billion3. Here, single fraudulent claims may get throughwithout question, but multiple losses such as serial claims for lost property may The Coalition Against Insurance Fraud estimates that the costs of other types Final estimate of the cost of insurance Evolving types of fraud In the digital era, scams are more convincing andeasier than ever to perpetrate at scale, with fraudstersconstantly finding innovative new ways to commitfraud, and insurers often having to play catch-up. It’srelatively easy to use technology to fake documents,voices, and images, making it much harder to tell ifsomeone is really who they say they are, and whether identity with which to commit fraud). The problem isgetting worse: according to data from cybersecuritycompany Crowdstrike, last year saw a 76% spike The dark web is not only a hotbed of stolendata such as passwords, email addresses, andbank details — it’s a place where criminals caneven purchase off-the-shelf phishing scams, witheverything required to defraud a particular companyor entit