Doctors in the top three hospitals defrauded commercial insurance and were sentenced to nearly 10 years in prison!

Involving 12 insurance companies including Chinese Life, Ping An Life and Pacific Life, a total of 47 life insurance policies, only serious illnesses involved in the insurance amount of nearly 8 million yuan, before the case was solved, the insurance company had paid 3 million yuan...

The author | Chen Chaoyang

Source| Medical Community (ID: vistamed)

Recently, the China Judgment Document Network and the Anhui Insurance Industry Association released the details of a major illness insurance fraud case, and the main culprit was a doctor in a public tertiary hospital.

Ming Moumou, the attending physician of the Second Department of Neurology of the South Hospital of Bozhou People's Hospital, took advantage of his position to use patients in his department or instructed relatives and friends to disguise themselves as patients to be hospitalized, and during hospitalization, fictitious patients suffered from acute myocardial infarction, and forged false cases to apply for major illness insurance claims from insurance companies. After investigation, it has been found that the gang has committed 7 crimes, and the value of a single case is up to 680,000 yuan.

As the main offender, Mr. Ming was sentenced to nine years and six months imprisonment for committing insurance fraud, and fined RMB 100,000 and returned the illegal gains.

Insurance companies pay for "suspicion"

"Another one!" In the second half of 2020, when receiving a claim report, the claim adjuster of an insurance company in Anhui Province was directly guilty of muttering. In previous inter-industry exchanges, insurance company claims adjusters found that over a period of time, there has been a significant increase in the number of cases of claims for major illnesses on the grounds of "acute myocardial infarction", and some of these reporters have highly similar behaviors.

Similar details include: the same hospital, the same doctor's signature, repeated mobile phone numbers, all have multiple insurance policies, and many people have purchased online consumer critical illness insurance with an annual payment of several hundred yuan in 2019... Shortly after purchasing the insurance, these people filed for a claim for a serious illness.

Claims adjusters also found that in the insurance company's claims investigation, some people were unclear about the details of the insurance, such as the mobile phone number, the name of the insured, the payment bank card, etc. During an interview with an insurance company, an insured person was vague about his or her hospitalization details, such as the doctor's gender and the admission process.

Some insured persons will also refuse to interview the insurance company for investigation. Once the insurance company initiates a claim investigation, some people will withdraw the claim or surrender the policy.

Such an abnormal situation has attracted the attention of the insurance industry in Anhui.

According to the anhui insurance association, as early as July 2020, Ruihua Health Insurance Company found doubts in a claim case involving Ming Moumou and entrusted Datong Insurance Valuation Co., Ltd. (hereinafter referred to as "Datong Valuation") to Bozhou City for investigation.

In the course of the investigation, the Datong Public Valuation Investigator remembered that in the past six months, he had received a number of insurance companies entrusted with the investigation of acute myocardial infarction cases in Bozhou, and the hospitals he visited were Bozhou People's Hospital.

After carefully comparing the materials of such investigation cases, the investigators found that all the cases were highly similar in terms of "hospital visiting", "ward visiting", "disease category", "hospitalization process" and "immediate risk after the observation period".

In order to further expand the scope of clue screening, Datong Public Valuation reported the case to the Anhui Insurance Industry Association (hereinafter referred to as the "Anhui Insurance Association"), and the Anhui Insurance Association quickly organized life insurance companies under its jurisdiction to conduct an investigation, requiring each company to sort out the data of all personnel who applied for claims due to major disease insurance (heart diseases such as myocardial infarction) in the jurisdiction of Bozhou Tancheng District since 2019, and a total of 141 data were feedback from 19 companies.

Big Data Comparison Reveals "Big Problems"

At the same time, the Anhui Insurance Association received 195 pieces of data sent by the Bozhou Municipal Medical Insurance Bureau from the Bozhou Municipal People's Hospital in the past 10 years diagnosed with myocardial infarction in the Department of Neurology, and the Medical Insurance Bureau asked the Anhui Insurance Association to cooperate in checking the insurance and claims of these data. And these patients are surprisingly consistent with the personnel who organized the industry investigation in the early stage.

At this time, the investigation is continuing. Through further verification and comparison of all the above information, many suspicious points were found, such as: more duplicate telephone numbers and duplicate addresses; in individual cases, while Company A applied for a claim, the insured surrendered or withdrawn the insurance policy of Company B for face-to-face interviews; Ming X pretended to be the insured to answer the claim telephone call, etc., and the suspicion of gang insurance fraud gradually increased.

Anhui Insurance Association based on the "January 2019 - September 2020, Bozhou People's Hospital, sudden acute myocardial infarction during hospitalization, coronary CTA after discharge, no follow-up treatment" and other keywords, as well as more than ten mobile phone numbers obtained before, once again organized the insurance companies under its jurisdiction to conduct risk screening, this round of investigation found a total of 10 insured people who have been insured because of "acute myocardial infarction", and the place of treatment of these personnel is without exception, all of which are the hospital where Ming is located.

The Anhui Banking and Insurance Regulatory Bureau transferred the case to the Economic Investigation Corps of the Anhui Provincial Public Security Department.

In the end, this case, with doctors as the main criminals and in-hospital personnel colluding inside and outside the hospital, used fictitious insurance accidents to defraud insurance claims to form an "industrial chain", and a series of insurance fraud cases involving particularly large amounts of money surfaced.

Doctors who are not busy at work have sold insurance

As a doctor, why did Ming Moumou start the idea of critical illness insurance?

According to Ming X's account, his usual work is not very busy, using his spare time to sell online insurance, joined the cloud insurance platform, and later terminated.

Ming's insurance fraud behavior is not smart, that is, using the convenience of his position to make patients without severe illness diagnosed with acute myocardial infarction and profit from it.

After investigation, Ming X let Yan X purchase ZhongAn Online Critical Illness Insurance, and At the same time, Ming X purchased Fosun Alliance, Everbright Sun Life and Ruihua Health Critical Illness Insurance for Yan X. After the above insurance passed the observation period, in May 2020, Ming arranged for Yan to be hospitalized in the Respiratory Medicine Department of the South Hospital of Bozhou People's Hospital, and arranged for Xia Cheng to impersonate Yan to do coronary artery CTA examination, so that Yan was diagnosed with acute myocardial infarction. Hou Ming, posing as Yan X, applied for a claim from Fosun United, ZhongAn Online, Everbright Sun Life and Ruihua Health Insurance, and successfully defrauded ZhongAn Online Insurance of 20,000 yuan (Ming X accounted for it as an existing one), and defrauded Everbright Sun Life Insurance of 128548 yuan.

In 2019, Mr. Ming purchased multiple insurances for his father-in-law, Wang Mou1. During January 2020, Mr. Ming arranged for Mr. Wang to be hospitalized at the Bozhou People's Hospital, and Mr. Ming, knowing that Mr. Wang 1 did not have an acute myocardial infarction, arranged for others to impersonate Mr. Wang 1 for coronary CTA examination, so that Mr. Wang 1 was diagnosed with acute myocardial infarction. After Wang Mou1 was discharged from the hospital, Ming used Wang Mou1's false medical records to declare critical illness insurance claims to the insurance company, declared mutual aid treasure to Alipay Company, defrauded Guohua Life, Taikang Online, and ZhongAn Online Critical Illness Insurance of 307771.64 yuan, and defrauded Alipay Company of 100,000 yuan of critical illness mutual aid. After the above-mentioned funds are received, they are transferred to the account controlled by Ming xxx.

In addition, Mr. Ming also helped others to carry out insurance fraud, and Mr. Ming obtained benefit fees from them.

Ming's defender believes that Ming's provision of clues to the public security organs during the investigation stage and reporting insurance fraud to others constitutes meritorious service and can be mitigated; voluntary admission of guilt and acceptance of punishment can be mitigated; if he has actively participated in the fight against the epidemic, he may be given a lighter punishment as appropriate; and it is recommended that a lighter punishment be given within the range of the sentencing recommendation.

The court found that the defendants Ming X and Zhu X carried out insurance fraud activities, and the amount was particularly huge, and the behavior constituted the crime of insurance fraud.

In the first instance judgment, Ming X committed insurance fraud and was sentenced to nine years and six months imprisonment and fined RMB 100,000; defendant Zhu X was sentenced to 10 years' imprisonment and fined RMB50,000 for the crime of insurance fraud.

The medical security fund is the people's "medical treatment money" and "life-saving money", and the commercial insurance fund is also the people's "emergency money".

The Criminal Law of the People's Republic of China stipulates that whoever fraudulently obtains social insurance benefits such as pensions, work injuries, unemployment or other social security benefits by fraud, falsification of supporting materials or other means is an act of defrauding public or private property. Whoever defrauds public or private property of a particularly large amount or has other particularly serious circumstances may be sentenced to fixed-term imprisonment of not less than 10 years or life imprisonment, and shall also be fined or have his property confiscated. The crime of insurance fraud includes five situations, such as the insured, the insured or the beneficiary, fabricating an insured accident that has not occurred and defrauding the insurance money.

Source:

Anhui Insurance Industry Association: "The Main Offender of the 8 Million Insurance Fraud Gang Involved in the Case Was Sentenced to 10 Years in Prison"

Securities Times Brokerage China: 12 insurance companies were pitted, the details of a gang fraud case in Anhui were exposed, and a doctor was the main culprit... (This article is published by "Seeing the Medical Community", reprinted with permission, and the author and source are indicated at the beginning of the article.) ）

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