Financial regulatory authorities, insurance group (holding) companies, insurance companies, insurance professional intermediaries, bank insurance companies, insurance industry associations, insurance societies:
We are now issuing the 'Anti Insurance Fraud Work Measures' to you for your compliance and implementation.
State Administration of Financial Supervision and Administration
July 22, 2024
(This document is sent to the Financial Regulatory Bureau and local legal person insurance institutions)
Measures for Anti Insurance Fraud Work
CHAPTER I GENERAL PROVISIONS
Article 1 In order to prevent and resolve insurance fraud risks, enhance the comprehensive risk management capabilities of the insurance industry, protect the legitimate rights and interests of insurance activity parties, maintain market order, and promote high-quality development of the industry, this method is formulated in accordance with laws and regulations such as the Insurance Law of the People's Republic of China and the Criminal Law of the People's Republic of China, combined with the current development status of the industry.
Article 2 The insurance fraud referred to in these Measures (hereinafter referred to as fraud) refers to the act of using insurance contracts to seek illegal benefits, mainly including intentionally fabricating insurance subject matter to defraud insurance benefits; Fabricating insurance accidents that have not occurred, fabricating false accident causes, or exaggerating the extent of losses to defraud insurance benefits; Intentionally causing insurance accidents and defrauding insurance benefits.
The insurance fraud risk referred to in these Measures (hereinafter referred to as fraud risk) refers to the risk that the perpetrator of fraud carries out fraudulent activities, causing economic losses or other damages to the parties involved in insurance activities and the general public.
Article 3 The goal of anti fraud work is to establish a four in one work system of "regulatory guidance, institutional leadership, industry joint prevention, and collaboration". The anti fraud system and mechanism are basically sound, the momentum of fraud and illegal crimes is effectively curbed, the ability to prevent and resolve industry fraud risks is significantly improved, and consumers' anti fraud awareness is significantly enhanced.
article 4 Insurance institutions should establish a comprehensive fraud risk management system and gradually improve the workflow of multi-party early warning, intelligent control during the event, and retrospective management after the event.
Industry organizations should fully leverage the role of big data and industry joint defense in combating fraud and illegal crimes according to their respective responsibilities, strengthen the effective application of anti fraud intelligent tools, improve the monitoring, early warning, and disposal processes of industry fraud risks, and provide support for regulatory agencies, public security and judicial organs, and insurance institutions' anti fraud work.
Article 5 Insurance institutions and industry organizations should coordinate network security, data security, and innovative development according to their respective responsibilities, fulfill security protection obligations in accordance with the law, improve management systems, strengthen network security and data security protection, ensure necessary personnel and resource investment, adopt network security and data security management and technical measures, and ensure the safe and controllable operation of anti fraud information systems.
Article 6 Insurance institutions should take the protection of consumer rights and interests as the starting point and foothold of anti fraud work, continuously improve the quality and efficiency of insurance services, guide insurance intermediaries, third-party outsourcing service providers, consumers, and others to participate in insurance activities in accordance with the law, regulations, honesty, and trustworthiness, create a good order in the insurance market, and effectively protect the legitimate rights and interests of consumers.
Chapter 2 Anti Fraud Supervision and Management
Article 7 The State Administration for Financial Regulation and its dispatched agencies shall supervise fraud risk management in accordance with the law.
Article 8 The State Administration for Financial Regulation and its dispatched agencies should establish an anti fraud regulatory framework, improve the anti fraud regulatory system, strengthen guidance on anti fraud work for insurance institutions and industry organizations, promote communication, cooperation, and information exchange with public security and judicial organs, relevant industry regulatory departments, and local government functional departments, and strengthen cross-border anti fraud cooperation.
Article 9 The State Administration for Financial Regulation and its dispatched agencies should guide insurance institutions to carry out the following work:
（1） Establish a sound fraud risk management system;
（2） Preventing and responding to fraud risks;
（3） Participate in anti fraud industry collaboration;
（4） Carry out anti fraud publicity and education.
Article 10 The State Administration for Financial Regulation and its dispatched agencies regularly inspect and evaluate the soundness and effectiveness of the fraud risk management system of insurance institutions, mainly including:
（1） Implementation of anti fraud regulatory provisions;
（2） The development of internal fraud risk management system;
（3） Establishment of fraud risk management organizational structure and personnel performance;
（4） The completeness, operability, and operational status of the fraud risk management process;
（5） Construction and operation of fraud risk management information system;
（6） Anti fraud collaboration situation;
（7） Fraud risk and case handling situation;
（8） Anti fraud training and publicity education situation;
（9） The situation of network security, data security, and personal information protection.
Article 11 The State Administration for Financial Regulation and its dispatched agencies continuously supervise the fraud risk management of insurance institutions through regulatory evaluation, risk warning, notification, and interviews. If insurance institutions violate the provisions of these Measures and cause adverse consequences, the State Administration for Financial Regulation and its dispatched agencies shall take regulatory measures or impose administrative penalties in accordance with the Insurance Law of the People's Republic of China and other laws and regulations.
Article 12 The State Administration of Financial Regulation guides industry organizations such as banks, insurance companies, insurance associations, and insurance societies to deepen industry cooperation, establish mechanisms for data sharing and fraud risk information exchange within and outside the industry, strengthen cooperation in risk disposal, jointly carry out industry actions to combat fraud, organize anti fraud publicity and education, deepen theoretical research and academic exchanges, and jointly promote anti fraud work.
The dispatched agencies of the State Administration of Financial Regulation should guide local insurance industry associations, insurance institutions, and their branches to improve anti fraud organizations according to actual situations, and may establish or jointly establish anti fraud centers, anti fraud offices, etc. with public security organs.
Chapter 3 Fraud Risk Management of Insurance Institutions
Article 13 Insurance institutions should bear the main responsibility for fraud risk management, establish and improve fraud risk management systems and mechanisms, standardize operating procedures, improve information systems, handle fraud risks prudently, strengthen industry cooperation, carry out anti fraud communication and training, publicity and education, and fulfill reporting obligations.
Article 14 The fraud risk management system of insurance institutions should include the following basic elements:
（1） Effective supervision and management by the board of directors, supervisory board (supervisors), or professional committees and management responsible for fulfilling the duties of the supervisory board;
（2） Institutional mechanisms that are suitable for the nature, scale, and risk characteristics of the business;
（3） Fraud risk management organizational structure and process settings;
（4） Responsibilities, authority allocation, and accountability mechanisms;
（5） Fraud risk identification, measurement, assessment, monitoring, and disposal procedures;
（6） Internal control and supervision mechanisms;
（7） Fraud Risk Management Information System;
（8） Anti fraud training and talent team building;
（9） Anti fraud publicity and education;
（10） Participation and cooperation in anti fraud collaboration mechanisms;
（11） Building a culture of honesty, trustworthiness, and compliance.
Article 15 Insurance institutions should regularly evaluate the effectiveness of their fraud risk management system based on comprehensive consideration of factors such as business development, technological updates, and market changes, and determine whether relevant strategies, systems, and procedures need to be updated and revised based on the evaluation results.
Insurance institutions shall submit an evaluation report on the effectiveness of their fraud risk management system for the previous year to the State Administration for Financial Regulation or its dispatched agencies in the first quarter of each year. Provincial branches of insurance institutions shall submit a fraud risk management system effectiveness evaluation report in accordance with the requirements of local dispatched institutions.
Article 16 Insurance institutions should establish a fraud risk management system, clarify the roles, responsibilities, and reporting paths of the board of directors, supervisory board (supervisors), or professional committees, management, fraud risk management leaders, and anti fraud functional departments responsible for fulfilling the duties of the supervisory board in fraud risk management, standardize operational procedures, and strictly assess and hold accountable the implementation of the system.
Article 17 Insurance institutions should reasonably determine the fraud risk control points for various business and management activities, clarify the review departments and approval authorities for fraud risk management related matters, implement standardized and unified business and management processes, cover fraud risk control to key business units, strengthen risk information verification at the underwriting and claims ends, and improve the quality and efficiency of claims.
Insurance institutions should strengthen integrity education and compliance culture construction, improve personnel selection and on-the-job performance inspection mechanisms, strengthen employee behavior management, conduct investigations into abnormal behavior of employees, and strictly prevent internal personnel fraud.
Insurance institutions should carefully choose insurance intermediary business partners or outsourcing service providers related to the business, and strengthen anti fraud supervision.
Article 18 Insurance institutions should establish a fraud risk identification mechanism to assess the fraud risks faced by key business units, the likelihood and degree of harm caused by such risks, select appropriate risk management strategies and tools, control the development trend of events, compensate for asset losses, and properly resolve risks.
Article 19 Insurance institutions should establish fraud risk management information systems or embed existing information systems into relevant functions, and ensure that internal standards for business element data are aligned with industry standards to ensure the authenticity, completeness, accuracy, and standardization of fraud risk management related data.
Insurance institutions should handle and use consumer personal information and industry data information in accordance with the law to ensure data security and completeness.
Article 20 Insurance institutions should incorporate anti fraud publicity and education into consumers' daily education and centralized education activities, establish diversified anti fraud publicity and education channels, carry out anti fraud publicity through official websites, mobile Internet applications, business places, etc., improve consumers' awareness of fraud, and enhance consumers' awareness and ability to prevent fraud.
Article 21 If insurance institutions discover fraudulent clues that may involve other insurance institutions, they should report to the China Banking and Insurance Corporation or local insurance industry associations and anti fraud organizations to verify and link the fraudulent clues.
Insurance institutions should establish and improve a fraud clue investigation mechanism, actively cooperate with industry organizations to carry out clue linking, risk investigation, case handling, and other work.
Insurance institutions should establish incentive mechanisms to commend and reward units and individuals who have achieved outstanding results in reporting, investigating, and combating fraud and illegal crimes.
Article 22 Insurance institutions carrying out agricultural insurance, first (set) major technical equipment insurance, key new material first batch application insurance, and other insurance types that are subsidized by the finance department should conduct continuous evaluations of fraud risks separately and develop reasonable fraud risk management measures based on the results.
Insurance institutions should strengthen supervision over institutions that assist in handling business, and shall not offset the insurance premiums that policyholders should pay or the insurance premium subsidies provided by the government by means of false claims, false expense reporting, false policy refunds, or withholding, misappropriating insurance premiums, misappropriating operating funds, etc. It is prohibited for any unit or individual to misappropriate, withhold, or embezzle the insurance benefits that insurance institutions should compensate the insured.
Article 23 After receiving claims or requests for insurance benefits from policyholders, insured persons, or beneficiaries, insurance institutions should promptly handle them in accordance with laws, regulations, and contractual agreements. Without conclusive evidence or clues, they shall not use suspected fraud as an excuse to delay claims or unreasonably refuse claims.
Chapter 4 Anti Fraud Industry Cooperation
Article 24 The Insurance Industry Association should play a role in promoting industry self-discipline and coordination under the guidance of the State Administration for Financial Regulation, and undertake the following responsibilities:
（1） Establish a system of anti fraud joint meetings, regularly convene joint meetings to coordinate and promote industry anti fraud work;
（2） Establish a professional talent pool for anti fraud and organize anti fraud communication and training;
（3） Organize anti fraud themed education and public welfare publicity activities;
（4） Strengthen communication and cooperation with other industries, self regulatory organizations, or international anti fraud organizations;
（5） Organize research on anti fraud topics;
（6） Submit a written report on the anti fraud work of the previous year to the State Administration for Financial Regulation in the first quarter of each year;
（7） Other anti fraud work that should be undertaken.
Article 25 Banks, insurance and credit companies should fully leverage the advantages of centralized management of big data platforms under the guidance of the State Administration of Financial Regulation and its dispatched agencies, explore the establishment of industry anti fraud information platforms, anti fraud intelligence centers and other infrastructure for multiple insurance types, monitor and analyze industry fraud risks, conduct centralized screening of suspicious fraud data, and hand over discovered fraud clues to local insurance industry associations, anti fraud organizations, and insurance institutions for verification. If suspected of committing a crime, report it to the public security organs in a timely manner.
The dispatched agencies of the State Administration of Financial Regulation, local insurance industry associations, and anti fraud organizations can refer to the above model to organize big data anti fraud work within their jurisdiction.
Article 26 Local insurance industry associations and anti fraud organizations should, under the guidance of the dispatched institutions of the State Administration of Financial Regulation, adhere to the work policy of "service, communication, coordination, and self-discipline", and undertake the following responsibilities:
（1） Establish an anti fraud cooperation mechanism within the jurisdiction;
（2） Publish fraud risk alerts and warnings within the jurisdiction, and explore the establishment of a fraud risk indicator system within the jurisdiction;
（3） Organize and coordinate insurance institutions within the jurisdiction to cooperate with banks, insurance and credit companies to carry out fraud clue verification and collusion work, improve relevant mechanisms such as case investigation, transfer for filing, and evidence retrieval;
（4） Explore the establishment of a local anti fraud information platform to provide information and data support for fraud risk analysis and early warning within the jurisdiction, organize investigations and judgments on regional fraud clues, and cooperate with public security organs in cracking down on them;
（5） Strengthen anti fraud cooperation and coordination with other supervisory departments or self regulatory organizations, enhance data and information sharing, and provide convenience for anti fraud work;
（6） Organize and carry out anti fraud education and public welfare publicity activities within the jurisdiction;
（7） Establish a professional talent pool and case library for anti fraud within the jurisdiction, and organize anti fraud exchange and training;
（8） Submit a written report on the anti fraud work of the previous year to the local agency in the first quarter of each year;
（9） Other anti fraud work that should be undertaken.
Article 27 Banks, insurance companies, local insurance industry associations, anti fraud organizations, insurance institutions, etc. should strictly abide by personal information protection laws and regulations, strengthen the full lifecycle management of personal information, establish institutional mechanisms for information collection, storage, use, processing, transmission, provision, deletion, etc., clarify the purpose of information use and information processing rights and responsibilities, and strictly control the scope and authority of information use. Without authorization from the information subject or permission from laws and regulations, no institution shall disclose or provide personal information to the public in written, oral, or other forms.
Article 28 Banks, insurance companies, local insurance industry associations, anti fraud organizations, insurance institutions, etc. should regularly exchange and cooperate on the construction of anti fraud information systems, the design of fraud indicators and monitoring models, fraud case investigations, and the sharing of typical cases.
Chapter 5 Collaboration among Anti Fraud Parties
Article 29 The State Administration for Financial Regulation and its dispatched agencies should establish and improve a mechanism for the connection between anti fraud administrative law enforcement and criminal justice with public security organs, people's procuratorates, and people's courts, and strengthen cooperation in unified legal application, situation reporting, information sharing, information release, case transfer, investigation and evidence collection, case consultation, judicial advice, and other aspects.
Article 30 If the State Administration for Financial Regulation and its dispatched agencies discover fraudulent and illegal activities suspected of committing crimes, they shall promptly transfer the case clues to the public security organs in accordance with the relevant provisions of administrative law enforcement agencies for transferring suspected criminal cases, and copy the case transfer letter to the people's procuratorate at the same level. Those suspected of committing official crimes shall be promptly transferred to the disciplinary inspection and supervision organs.
The State Administration for Financial Regulation and its dispatched agencies should strengthen law enforcement cooperation with public security organs and people's procuratorates, and carry out joint crackdowns or supervision on key areas, new and major fraud cases.
Article 31 The State Administration for Financial Regulation and its dispatched agencies should establish and improve cooperation mechanisms with market supervision, judicial administration, medical security and other departments, and strengthen cooperation in information sharing, notification and consultation, clue transfer, exchange and mutual training, joint law enforcement and other aspects.
Article 32 The State Administration of Financial Regulation and its dispatched agencies should strengthen coordination and linkage with local government functional departments, promote the establishment of a normalized communication mechanism for anti fraud, timely report important regulatory information, key risk clues, and major special actions, and strengthen information sharing and law enforcement cooperation.
Article 33 The State Administration of Financial Regulation and its dispatched agencies should strengthen cross-border cooperation in anti fraud, establish a sound framework for cross-border communication and cooperation, guide industry organizations to strengthen communication and liaison with overseas anti fraud organizations, and carry out anti fraud cooperation in cross-border commissioned investigations, information inquiry and notification, exchange visits, and other aspects.
Chapter VI Supplementary Provisions
Article 34 The insurance institutions referred to in these Measures refer to insurance companies, mutual insurance organizations, and their branches established with the approval of the State Administration for Financial Regulation and its dispatched agencies. Insurance group (holding) companies, reinsurance companies, insurance professional intermediaries, and other institutions with anti fraud functions shall carry out anti fraud related work in accordance with these measures based on their own business practices and risk characteristics.
Article 35 The evaluation methods and indicators for the effectiveness of the fraud risk management system of insurance institutions shall be separately stipulated.
Article 36 The State Administration for Financial Regulation is responsible for interpreting and revising these measures.
Article 37 These measures shall come into effect on August 1, 2024, and the Notice of the China Insurance Regulatory Commission on Issuing the Anti Insurance Fraud Guidelines (CBIRC [2018] No. 24) shall be simultaneously abolished.
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