In December 2021, the Jilin Songyuan police received a report from Taikang Life Insurance Company, saying that when the company was combing through the relevant information of insurance claim cases, it found that many people were suspected of insurance fraud.
The Songyuan police investigation found that Wang Mouling, Wang Mouhui, Liang Mouru and others in the city took the initiative to purchase critical illness insurance for many people with thyroid nodules, and concealed the plot of "thyroid nodules" when they applied for insurance. A few months later, a number of policyholders were diagnosed with thyroid cancer, applied for compensation and received compensation, and the compensation was distributed to Wang Mouling, Wang Mouhui, Liang Mouru, etc.
After that, Wang Mouling, Wang Mouhui, and Liang Mouru were arrested and prosecuted for insurance fraud. During the trial, the defendant argued that all the claims filed by the policyholders in this case were based on the real facts of thyroid cancer, and the time of cancer occurred after the insurance was insured. "Sickness insurance" should be a civil dispute, not a criminal offence.
After the first and second instance of the case, the court ruled that the above three defendants were guilty of insurance fraud.
↑ Verdict
The Songyuan Intermediate People's Court held that the three defendants violated the provisions of the insurance law by deliberately fabricating the subject matter of insurance that did not match the actual insurance subject matter and defrauding the insurance money when entering into an insurance contract with the insurer, which met the constitutive elements of the crime of insurance fraud. In January 2024, Wang Mouling and Wang Mouhui were finally sentenced to 12 years and 11 years in prison respectively, and Liang Mouru was "sentenced to three suspended four".
After getting the verdict, the families of Wang Mouling and Wang Mouhui believed that "concealing thyroid nodules and taking out insurance" was at most a civil dispute, and said that they would appeal to a higher court.
The insurance company reported the crime
Prosecutors charged 11 counts of insurance fraud
"When the company combed through the relevant information of the insurance claim case, it was found that the customers Wang, Gao and Huo who were insured by the company were suspected of insurance fraud, and these people had a very large insurance amount, and they were all insured within one year of insurance, which was very abnormal. "In December 2021, the staff of the Jilin Provincial Branch of Taikang Life Insurance Co., Ltd. reported to the Economic Investigation Detachment of the Songyuan Public Security Bureau, suspecting that the above-mentioned persons did not have the disease claimed by the insurance, but fabricated an insurance accident and defrauded the insurance compensation.
After that, the local police arrested Wang Mouling, Wang Mouhui, Liang Mouru and others through investigation.
According to investigation, Wang Mouhui and Wang Mouling are sisters. Wang Mouling said that Liang was her classmate.
The public prosecution alleged that between June 2019 and June 2020, there were 11 cases of insurance fraud, all of which involved Wang Mouling, 6 cases involving Wang Mouhui, and 4 cases of Liang Mouru. In addition, there are multiple people involved in the case, but they are not prosecuted or handled separately.
The first case of insurance fraud alleged by the prosecution occurred on June 29, 2019. According to the indictment, after Wang Mouling, Wang Mouhui and Shao Mouhua (handled in a separate case) jointly premeditated, knowing that Shao Mouhua had thyroid nodules and was suspected of malignant tumors, Wang Mouling paid the insurance premium, and Shao Mouhua insured the Hui Health critical illness insurance with an amount of 700,000 yuan at the Jilin Branch of Taikang Life Insurance Co., Ltd.
From February to March 2020, Shao Mouhua was diagnosed with papillary thyroid carcinoma and hospitalized for surgery after pathological examination of the lesion puncture. After being discharged from the hospital, Shao Mouhua applied for compensation from the insurance company on the grounds that he was suffering from thyroid cancer, and defrauded the insurance money of RMB 700,000. According to the prior agreement, defendants Wang Mouling and Wang Mouhui received an insurance payment of RMB 600,000, and Shao Mouhua received an insurance payment of RMB 100,000.
However, Liang Mouru purchased insurance in his own name. The prosecution alleges: On August 30, 2019, after the defendants Wang Mouling and Liang Mouru jointly premeditated, when they knew that Liang Mouru had thyroid nodules and was suspected of malignant tumors, Wang Mouling paid the insurance premium, and Liang Mouru insured himself with Taikang Life Insurance for a Hui Health critical illness insurance with an amount of 1 million yuan.
In May 2021, Liang was diagnosed with papillary thyroid carcinoma and hospitalized for surgery after pathological examination of the lesion puncture. After being discharged from the hospital, Liang applied for a claim from the insurance company on the grounds that he was suffering from thyroid cancer, and defrauded the insurance money of RMB 1 million. According to the prior agreement, Wang Mouling received 600,000 of them.
According to the prosecution's allegations, in addition to Taikang Life, the insurance company defrauded in the case also involved a number of companies such as Xinhua Life Insurance and Ping An Life.
The public prosecution held that the defendant Wang Mouling, together with others, violated insurance laws and regulations by using the method of fictitious insurance subject matter to defraud insurance companies of insurance money, committing 11 crimes, with a total amount of 6,887,400 yuan, defendant Wang Mouhui and others committing 6 crimes, with a total of 3,587,400 yuan, and defendant Liang Mouru committing 4 crimes, with a total of 2.5 million yuan, a particularly huge amount and a particularly serious circumstance.
The policyholders are all "acquaintances"
The defendant's family admits to "taking advantage of the loophole"
The Red Star News reporter noticed that among the policyholders in the 11 insurance fraud cases accused by the public prosecution, most of them were fellow villagers of Wang Mouling and Wang Mouhui, and some were even relatives.
As for how to find policyholders with thyroid nodules, Mr. Han, Wang's husband, said, "They are all acquaintances, and only when they know each other do they help them buy insurance." (Thyroid nodules) are all said by the policyholders themselves. ”
The Red Star News reporter once called the family of Huo Mouhong, an insured person funded by Wang Mouhui and Wang Mouling, who was insured by Wang Mouhui and Wang Mouling, and the other party said that Huo Mouhong was a relative of the Wang sisters and had talked about Huo Mouhong's thyroid problems.
His family said that Huo Mouhong couldn't afford insurance, and the Wang sisters helped to buy and repay the claim, so they (the Wang sisters) should be given the money.
According to the prosecution's allegations, Huo Mouhong defrauded the insurance money of 800,000 yuan. According to the prior agreement, defendants Wang Mouling and Wang Mouhui received 600,000 yuan, and Huo Mouhong received 200,000 yuan.
Huo Mouhong's family said that after the incident, all the insurance money he obtained had been handed over.
Wang Mouling's husband, Mr. Han, admitted that he worked as a salesman for five or six months at the local Taikang Insurance Company in 2020. The reporter noticed that when Taikang Life reported the case, Mr. Han was detained on suspicion of insurance fraud, and was later released on bail and not prosecuted.
As for why Wang Mouling and others want to pay their own money to help others buy critical illness insurance, Mr. Han said, "This is beneficial to myself, there is a guarantee, and if I find a critical illness, the surgery insurance can reimburse me." ”
"Let's be honest, it's also taking advantage of this loophole. Mr. Han said.
"Deliberately fictitious subject matter of insurance"
The three defendants were found guilty in both the first and second trials
In this case, the procuratorate alleged that the three defendants violated insurance laws and regulations by using the method of fictitious insurance subject matter to defraud the insurance company of insurance money for the purpose of illegally obtaining insurance money, and they should all be investigated for criminal responsibility for the crime of insurance fraud. In the course of the joint crime, defendants Wang Mouling and Wang Mouhui were the principal offenders, and defendant Liang was an accomplice.
During the trial of the case, the defendant's defender said that it was not illegal for Wang Mouling to pay premiums for others and share the compensation money. The Insurance Law stipulates that if the insured agrees to the policyholder to conclude a contract for him/her, the policyholder shall be deemed to have an insurance interest in the insured. In this case, Wang Mouling obtained the consent of others to pay the insurance premiums for her, Wang Mouling was the actual insured, and Liang Mouru, Huo Mouhong and others were the insureds, and when the conditions for compensation were met, Wang Mouling received the pre-agreed proportion of the compensation money did not violate the law.
The defender argued that concealing the fact of thyroid nodules at the time of insurance application was not equivalent to fictitious insurance objects, but only a failure to fulfill the obligation to truthfully inform. The insured only recognized the fact of thyroid nodules before applying for insurance, and none of them were diagnosed with thyroid cancer after strict diagnosis, and did not have an accurate understanding of the benign malignancy of thyroid nodules and the probability of transforming into cancer. All the claims filed by the policyholder in this case are based on the real facts of thyroid cancer, and the time of cancer occurrence occurred after the insurance was insured. Whether or not to have cancer is not something that Wang Mouling and others can control and decide.
The People's Court of Ningjiang District, Songyuan City, in the first instance, held that concealing illness and taking out insurance was an act of concealing the dangers of insurance to defraud the insurance money, and it was "deliberately fabricating the subject matter of insurance". In this case, the perpetrator concealed that the health required by the health insurance contract did not exist, and by concealing the truth of the disease he had suffered, he fabricated the fact of physical health, which was an act of fabricating the subject matter of the insurance. This act caused the insurer to enter into an insurance contract with the insurer contrary to its true intentions, and then applied for a claim to obtain insurance money, which met the elements of the crime of insurance fraud.
In August 2023, the court found that the three defendants were guilty of insurance fraud, and sentenced them to 12 years, 11 years, and 5 years in prison respectively, and fines, and ordered them to return compensation to the victim's insurance company.
After receiving the judgment, the three defendants appealed, and the Songyuan Intermediate People's Court of the second instance held that the facts found by the original trial court were clear and the evidence was credible and sufficient. In addition to changing Liang Mouru's sentence from five years to "three suspended sentences and four suspended sentences", the rest upheld the original sentence.
The Red Star News reporter noticed that in the course of the second instance of this case, the defense lawyer had proposed that the keywords "concealment", "thyroid nodules" and "insurance" were searched on the China Judgment Document Network, and almost all the cases of "concealment of thyroid nodules for insurance" were civil cases. In this regard, according to the above three keywords, the reporter searched on the judgment document network and found that a total of 1,181 documents were retrieved, including 1,180 civil cases and 1 criminal case document, which had nothing to do with insurance fraud.
Fu Jian, director of Henan Zejin Law Firm, believes that if the policyholder deliberately conceals that there are nodules in the body, it is a failure to fulfill the obligation to truthfully inform, and the insurance company has the right to terminate the insurance contract and not settle the claim, which is a civil dispute. If, for the purpose of illegal possession, the policyholder is looking for a thyroid nodule and fraudulently obtaining insurance premiums, so as to make a profit, he shall bear criminal responsibility.
Chen Jiawei, a lawyer at Beijing Dayu Law Firm, believes that the core issue in this case is whether the failure to truthfully inform the physical condition of the life insurance insurance constitutes insurance fraud. If a patient with a thyroid nodule can take out the insurance according to the insurance contract, it does not constitute fraud, and if the insurance company expressly agrees or informs that the patient with a thyroid nodule cannot be insured, it constitutes fraud.
Insurance companies involved:
Customers need to answer truthfully about their health conditions for underwriting
The reporter noticed that in the "Statement of Health and Occupation of the Insured" on the "Critical Illness Insurance" policy of Taikang Life Insurance involved in the case, there was a requirement to inform of thyroid diseases. It is stipulated in the policy that if the company deliberately fails to fulfill the obligation to tell the truth, the company shall not be liable for the insurance accident that occurred before the termination of this contract, and the insurance premium will not be refunded.
Wang Mouling once told the court that if they (the policyholders) were diagnosed with thyroid cancer before applying for insurance, they would not contact them for insurance, and the salesman would not be able to sign an insurance contract with them.
As for whether it is possible to buy critical illness insurance with thyroid disease, the Red Star News reporter called the official customer service of Taikang Insurance to ask. The operator said that there is a health notice for the purchase of such "critical illness insurance", and the customer needs to answer the health situation truthfully and submit it to the company for review by the underwriting department, and the application can only be successfully applied for.
The above-mentioned staff said that the underwriting conclusions are different, resulting in different insurance results. Some customers may not be allowed to apply for insurance because of their serious thyroid condition, and some may also be allowed to apply for critical illness insurance, but they will not be compensated for thyroid diseases, and other normal compensation will be paid. If there is no impact after the underwriting is passed, as long as it meets the definition in critical illness and the definition of disease type, it will be compensated, depending on the situation.
Red Star News Chief Reporter Zhang Yanliang
Editor-in-charge: Deng Minguang
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