| Notice of the China Insurance Regulatory Commission on Issuing the Anti-Insurance Fraud Guidelines | | 中国保监会关于印发《反保险欺诈指引》的通知 |
| (No. 24 [2018] of the China Insurance Regulatory Commission) | | （保监发〔2018〕24号） |
| All local offices of the China Insurance Regulatory Commission ("CIRC"); the China Insurance Information Technology Management Co., Ltd.; the Insurance Association of China ("IAC"); the Insurance Institute of China; and all insurance group (holding) companies, insurance companies, and specialized insurance intermediary institutions: | | 各保监局，中国保险信息技术管理有限责任公司，中国保险行业协会、中国保险学会，各保险集团（控股）公司、保险公司、保险专业中介机构： |
| For the purposes of protecting the lawful rights and interests of insurance consumers, practically preventing and resolving insurance fraud risks, and promoting the sound and sustainable development of the insurance industry and the building of the social credit system, the CIRC developed the Anti-Insurance Fraud Guidelines, which are hereby issued to you for your conscientious implementation based on the actual circumstances. | | 为保护保险消费者合法权益，切实防范化解保险欺诈风险，促进保险业健康可持续发展及社会诚信体系的构建，中国保监会制定了《反保险欺诈指引》，现印发给你们，请结合实际认真贯彻执行。 |
| China Insurance Regulatory Commission | | 中国保监会 |
| February 11, 2018 | | 2018年2月11日 |
| Anti-Insurance Fraud Guidelines | | 反保险欺诈指引 |
| Chapter I General Provisions | | 第一章 总 则 |
| Article 1 For the purposes of improving the capability of comprehensive risk management of the insurance industry and preventing and resolving insurance fraud risks, these Guidelines are developed according to the Insurance Law of the People's Republic of China, the Criminal Law of the People's Republic of China, and other laws and regulations. | | 第一条 为提升保险业全面风险管理能力，防范和化解保险欺诈风险，根据《中华人民共和国保险法》、《中华人民共和国刑法》等法律法规，制定本指引。 |
| Article 2 For the purpose of these Guidelines, "insurance organization" means an insurance group (holding) company, insurance company or any branch office thereof formed with the approval of the China Insurance Regulatory Commission (hereinafter referred to as the "CIRC") or any dispatched office thereof (hereinafter referred to as the "dispatched office"). Professional insurance intermediary agencies, reinsurance companies and others institutions possessing anti-insurance fraud functions shall conduct the work relating to combating insurance fraud according to these Guidelines, mutatis mutandis. | | 第二条 本指引所称保险机构，是指经中国保险监督管理委员会（以下简称保监会）及其派出机构（以下简称派出机构）批准设立的保险集团（控股）公司、保险公司及其分支机构。保险专业中介机构、再保险公司和其他具有反保险欺诈职能的机构参照本指引开展反欺诈相关工作。 |
| Article 3 "Insurance fraud" (hereinafter referred to as the "fraud") means conduct of seeking illicit interests under the guise of insurance or by insurance contract, mainly including fraudulent conduct in the insurance benefit fraud category, fraudulent conduct in the illegal insurance business category, and fraudulent conduct in the insurance contract fraud category. Unless otherwise specified, for the purpose of these Guidelines, "fraud" means only fraudulent conduct in the insurance benefit fraud category, mainly including intentionally fabricating an insured object for the purpose of obtaining insurance benefit by fraud; fabricating an insured event that did not take place, or fabricating the cause of an accident, or exaggerating loss severity for the purpose of obtaining insurance benefit by fraud; and intentionally causing an insured event for the purpose of obtaining insurance benefit by fraud. | | 第三条 保险欺诈（以下简称欺诈）是指假借保险名义或利用保险合同谋取非法利益的行为，主要包括保险金诈骗类欺诈行为、非法经营保险业务类欺诈行为和保险合同诈骗类欺诈行为等。除特别说明，本指引所称欺诈仅指保险金诈骗类欺诈行为，主要包括故意虚构保险标的，骗取保险金；编造未曾发生的保险事故、编造虚假的事故原因或者夸大损失程度，骗取保险金；故意造成保险事故，骗取保险金的行为等。 |
| For the purpose of these Guidelines, "insurance fraud risk" (hereinafter referred to as the "fraud risk") means the risk that a perpetrator of fraud causes financial damage or any other damage to the insurance industry, insurance consumers or the public by conducting fraudulent activities. | | 本指引所称保险欺诈风险（以下简称欺诈风险）是指欺诈实施者进行欺诈活动，给保险行业、保险消费者及社会公众造成经济损失或其他损失的风险。 |
| Article 4 The anti-fraud work aims to protect the lawful rights and interests of insurance consumers, maintain the order of the insurance market, and promote the sound development of the insurance industry. | | 第四条 反欺诈工作以保护保险消费者合法权益，维护保险市场秩序，促进保险行业健康发展为目标。 |
| Article 5 The CIRC and its dispatched offices shall regulate the fraud risk management of insurance organizations as legally required. | | 第五条 保监会及其派出机构依法对保险机构的欺诈风险管理工作实施监管。 |
| Chapter II Fraud Risk Management of Insurance Institutions | | 第二章 保险机构欺诈风险管理 |
| Article 6 An insurance organization shall undertake the primary responsibility for fraud risk management, establish and improve fraud risk management rules and mechanisms, standardize operational process, properly dispose of fraud risks, and discharge reporting obligation. | | 第六条 保险机构应当承担欺诈风险管理的主体责任，建立健全欺诈风险管理制度和机制，规范操作流程，妥善处置欺诈风险，履行报告义务。 |
| Article 7 The fraud risk management system of an insurance organization shall include the following: | | 第七条 保险机构欺诈风险管理体系应包括以下基本要素： |
| (1) Effective oversight and management by the board of directors, the board of supervisors and the management. | | （一）董事会、监事会、管理层的有效监督和管理； |
| (2) Rules and systems commensurate with the nature and size of business and risk characteristics. | | （二）与业务性质、规模和风险特征相适应的制度机制； |
| (3) The organizational structure and process of fraud risk management. | | （三）欺诈风险管理组织架构和流程设置； |
| (4) Division of duties and powers and appraisal and accountability mechanisms. | | （四）职责、权限划分和考核问责机制； |
| (5) Procedures for identification, measurement, assessment, monitoring, and disposition of fraud risks. | | （五）欺诈风险识别、计量、评估、监测和处置程序； |
| (6) Internal control and oversight mechanism. | | （六）内部控制和监督机制； |
| (7) Risk management information system. | | （七）欺诈风险管理信息系统； |
| (8) Reporting and crisis disposition mechanism. | | （八）报告和危机处理机制。 |
| Section 1 Rules System and Organizational Structure | | 第一节 制度体系与组织架构 |
| Article 8 An insurance organization shall develop fraud risk management rules to specify the roles, duties and reporting channels in fraud risk management of the board of directors and its special commissions, the border of supervisors (supervisors), the management, and relevant departments, standardize operational process, and strictly implement appraisal and accountability rules. | | 第八条 保险机构应制定欺诈风险管理制度，以明确董事会及其专门委员会、监事会（监事）、管理层、相关部门在欺诈风险管理中的作用、职责及报告路径，规范操作流程，严格考核、问责制度执行。 |
| Article 9 The board of directors of an insurance organization shall undertake the ultimate responsibility for fraud risk management and have the following major duties: | | 第九条 保险机构董事会承担欺诈风险管理的最终责任，董事会主要职责包括： |
| (1) Determining the strategic plan and overall policy for fraud risk management. | | （一）确定欺诈风险管理战略规划和总体政策； |
| (2) Examining and approving basic rules for risk management. | | （二）审定欺诈风险管理的基本制度； |
| (3) Overseeing the effectiveness of the implementation of the fraud risk management rules. | | （三）监督欺诈风险管理制度执行有效性； |
| (4) Deliberating fraud risk management reports submitted by the management or the risk management commission. | | （四）审议管理层或风险管理委员会提交的欺诈风险管理报告； |
| (5) Adjusting and refining the fraud risk management policy based on the internal audit results and supervising the management to take corrective measures. | | （五）根据内部审计结果调整和完善欺诈风险管理政策，监督管理层整改； |
| (6) Deliberating other material matters affecting fraud risk management. | | （六）审议涉及欺诈风险管理的其他重大事项； |
| (7) Duties otherwise provided by any law or regulation. | | （七）法律、法规规定的其他职责。 |
| The board of directors may, according to the company bylaws and its rules of procedure, authorize the risk management commission under it to discharge its certain duties of fraud risk management. | | 董事会根据公司章程和董事会议事规则，可以授权其下设的风险管理委员会履行其欺诈风险管理的部分职责。 |
| Article 10 The management of an insurance organization shall undertake the responsibility for effecting fraud risk management and have the following major duties: | | 第十条 保险机构管理层承担欺诈风险管理的实施责任，主要职责包括： |
| (1) Developing fraud risk management rules, filing them with the board of directors, and implementing them with the approval of the board of directors. | | （一）制定欺诈风险管理制度，报董事会批准后执行； |
| (2) Establishing an organizational structure for fraud risk management, specifying the several duties and powers of functional departments, business departments and other departments, and determining the paths for reporting fraud risks. | | （二）建立欺诈风险管理组织架构，明确职能部门、业务部门以及其他部门的职责分工和权限，确定欺诈风险报告路径； |
| (3) Disposing of material fraud risk events or projects as authorized by the board of directors or submitting such events or projects to the board of directors for deliberation when necessary. | | （三）对重大欺诈风险事件或项目，根据董事会授权进行处置，必要时提交董事会审议； |
| (4) Regularly assessing the general status of fraud risk management and filing a report with the board of directors. | | （四）定期评估欺诈风险管理的总体状况并向董事会提交报告； |
| (5) Establishing and implementing a fraud risk management appraisal and accountability mechanism. | | （五）建立和实施欺诈风险管理考核和问责机制； |
| (6) Duties otherwise provided by any law or regulation or granted by the board of directors. | | （六）法律、法规规定的或董事会授予的其他职责。 |
| Article 11 The board of supervisors (supervisors) shall supervise and evaluate the discharge of duties by the board of directors and the management in fraud risk management. | | 第十一条 监事会（监事）应对董事会及管理层在欺诈风险管理中的履职情况进行监督评价。 |
| Article 12 An insurance organization shall appoint a person in charge of fraud risk management (hereinafter referred to as the "person in charge") and inform the CRIC in writing. A person in charge shall be a senior executive able to undertake the responsibility for fraud risk management and have the following duties: | | 第十二条 保险机构应当指定欺诈风险管理负责人（以下简称负责人），并以书面形式告知保监会。负责人应由能够承担欺诈风险管理责任的高级管理人员担任，职责包括： |
| (1) Breaking down the responsibility for fraud risk management and specifying the chain of risk responsibility. | | （一）分解欺诈风险管理责任，明晰风险责任链条； |
| (2) Organizing and implementing risk management measures and internal control development measures. | | （二）组织落实风险管理措施与内控建设措施； |
| (3) Overseeing the implementation of the rules and procedures for fraud risk management. | | （三）监督欺诈风险管理制度和程序的实施； |
| (4) Making proposals for the strategy, plan, policy and procedure in relation to the fraud risk management of the insurance organization. | | （四）为保险机构欺诈风险管理战略、规划、政策和程序提出建议； |
| (5) Reviewing the annual fraud risk reports and other documents issued by the anti-fraud functional departments. | | （五）审核反欺诈职能部门出具的欺诈风险年度报告等文件； |
| (6) Reporting to the CIRC and accepting regulatory inquiry, among others. | | （六）向保监会报告，接受监管质询等。 |
| An insurance organization shall provide necessary conditions for the person in charge to discharge his/her duties. If the person in charge fails to discharge his/her duties or encounters any difficulty over the course of the discharge, he/she shall file written statements with the CIRC. If the person in charge cannot continue to discharge his/her duties on account of changes of his/her office or work, the insurance organization shall, within ten working days, separately appoint another person in charge and report the modification to the CIRC. | | 保险机构应当为负责人履行职责提供必要的条件。负责人未能履行职责或者在履行职责过程中遇到困难的，应当向保监会提供书面说明。负责人因岗位或者工作变动不能继续履行职责的，保险机构应在10个工作日内另行指定负责人并向保监会报告变更。 |
| Article 13 An insurance organization shall appoint a body of its head office as the anti-fraud functional department and establish a separate post of anti-fraud management responsible for the implementation of the anti-fraud risk management measures. The anti-fraud functional department shall discharge the following duties: | | 第十三条 保险机构应在总部指定内设机构作为反欺诈职能部门，并设立专职的反欺诈管理岗位，负责欺诈风险管理措施的执行。反欺诈职能部门应当履行下列职责： |
| (1) Proposing specific policies, operating rules and procedures, and operating standards for fraud risk management, reporting to the board of directors or the management, and implementing them with the approval of the board of directors or the management. | | （一）拟定欺诈风险管理的具体政策、操作规程和操作标准，报董事会或管理层批准后执行； |
| (2) Establishing and organizing the implementation of the processes of identification, measurement, assessment, monitoring, and disposition of fraud risks. | | （二）建立并组织实施欺诈风险识别、计量、评估、监测和报告流程； |
| (3) Establishing and managing an anti-fraud information system. | | （三）建立并管理反欺诈信息系统； |
| (4) Organizing and launching anti-fraud investigations and risk screening. | | （四）组织开展反欺诈调查和风险排查； |
| (5) Coordinating the implementation of the anti-fraud operating rules and procedures by other departments. | | （五）协调其他部门执行反欺诈操作规程； |
| (6) Monitoring and analyzing fraud risk management and regularly submitting fraud risk reports to the management and the board of directors of the company and the CIRC. | | （六）监测和分析欺诈风险管理情况，定期向公司管理层、董事会和保监会提交欺诈风险报告； |
| (7) Providing anti-fraud training, exchanging anti-fraud experience, developing a fraud risk management culture, and conducting anti-fraud publicity and education. | | （七）提供反欺诈培训，开展反欺诈经验交流，建设欺诈风险管理文化，进行反欺诈宣传和教育； |
| (8) The work otherwise relating to fraud risk management. | | （八）与欺诈风险管理相关的其他工作。 |
| Article 14 An insurance organization shall guarantee effective fraud risk management and assign appropriate resources, including without limitation providing necessary funds, establishing necessary posts, assigning appropriate personnel, providing training, and granting fraud risk managers powers necessary for discharging their duties. The other departments of the insurance organization shall provide the anti-fraud functional department with support within their remit. | | 第十四条 保险机构应保障欺诈风险管理工作的有效开展，并配备适当的资源，包括但不限于提供必要的经费、设置必要的岗位、配备适当的人员、提供培训、赋予欺诈风险管理人员履行职务所必需的权限等。保险机构的其他部门应在职责范围内为反欺诈职能部门提供支持。 |
Article 15 A provincial insurance organization shall appoint any of its bodies as the anti-fraud functional department responsible for implementing local fraud risk management measures and assigning a certain proportion of full-time employees in according to the number of claims, size of premiums, risk characteristics, number of institutions, and other indicators. The provincial insurance organization shall inform the dispatched office in the place it is located of the anti-fraud organizational structure and the person in charge in writing.
．．．．．． | | 第十五条 保险省级机构应指定内设机构作为反欺诈职能部门，负责本地区欺诈风险管理措施的执行，并按照赔案数量、保费规模、风险特征、机构数量等指标配备一定比例的专职工作人员。保险省级机构应以书面形式将反欺诈组织架构和负责人告知所在地派出机构。
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