Medical insurance fraud is an act of falsely reporting and lying about medical expenses that cannot be reimbursed.
What are the constitutive elements of insurance fraud?
(A) the object elements
The object of this crime is a dual object, which infringes on the property ownership of insurance companies and the national insurance system. Insurance refers to the commercial insurance behavior that the insured pays the insurance premium to the insurer (that is, the insurance company) according to the contract, and the insurer is responsible for the property losses caused by the possible accidents agreed in the contract when the insured dies, is disabled, is sick or reaches the age and time limit agreed in the contract. Insurance system is an economic system that uses social and collective forces to establish funds to compensate or pay the losses caused by specific dangerous accidents. It has the nature of mutual assistance and economic compensation, and it is a kind of social decentralization of personal danger. In modern society, the insurance system has become an increasingly important social security system, which is of great significance for ensuring the normal production and operation of enterprises, ensuring the stability of personal life and reducing the loss of social wealth. At the same time, insurance business has also become an important channel for accumulating construction funds to develop the national economy. Therefore, it is an important task of legal protection to ensure that the insurance system is inviolable and promote the sustainable development of the national economy and the safety of people's lives. Criminals defrauding insurance money not only infringes on the property ownership of insurance companies, but also infringes on the national insurance system and interferes with the normal development of insurance business.
The object of this crime is insurance money. Insurance premium, also known as insured amount and insured amount, is the highest limit of the insurer's liability to compensate or pay insurance money. It does not constitute this crime if the actor defrauds the property of an insurance company other than insurance money by deception.
(b) objective factors
The crime of insurance fraud is objectively manifested in the following five situations:
1. The insured deliberately fabricated the subject matter of insurance to defraud the insurance money.
2. The applicant, the insured or the beneficiary fabricates false reasons for the occurrence of the insured accident or exaggerates the degree of loss to defraud the insurance money.
3. The applicant, the insured or the beneficiary fabricates an insurance accident that has never happened to defraud the insurance money.
4. The applicant or the insured intentionally causes an insurance accident that causes property losses and defrauds the insurance money.
5. The insured or beneficiary intentionally causes the death, disability or illness of the insured to defraud the insurance money.
(3) Main elements
The subject of this crime is a special subject, which can only be composed of the applicant, the insured and the beneficiary. The insured, the insured and the beneficiary here can be both natural persons with criminal responsibility ability and reaching the age of criminal responsibility, or units. The so-called applicant refers to the person who has entered into an insurance contract with the insurer and has the obligation to pay the insurance premium according to the insurance contract; The insured refers to the person whose property or person is protected by the insurance contract and enjoys the right to claim insurance money, and the applicant can become the insured; Beneficiary refers to the person designated by the insured or the insured in the life insurance contract who has the right to claim insurance money. The applicant and the insured can be beneficiaries. In addition, if the appraisers, witnesses and property appraisers of insurance accidents intentionally provide false documents to provide conditions for others to cheat, they shall be punished as * * * insurance fraud. The unit can also constitute this crime, because the unit can also become the insured, the insured and the beneficiary.
(4) Subjective factors
Subjectively, this crime can only be intentional and has the purpose of illegally possessing insurance money. If the actor causes the insured accident due to negligence, or thinks that the insured accident did not actually happen due to misunderstanding, or exaggerates the accident loss due to miscalculation, and thus obtains the insurance money, it does not constitute a crime. As for the intention of this crime, it can be produced before or after the insurance; It may also happen before or after the insured accident. The time of intentional crime does not affect the nature of this crime, but it can be properly considered as a plot when sentencing.