Insurance Fraud Analysis 2025
The value of assets protected is growing, but detection systems are facing sophisticated fraudulent methods. Data from the past fiscal year confirm a persistent, yet structurally changing trend in insurance fraud within the insurance sector.
Analysis of insurance fraud
While the frequency of attempted fraudulent acts remains stagnant, the average claim amount is showing an upward trend. Domestic insurers, thanks to the implementation of advanced analytical tools, report high detection efficiency, with just one of the significant market players reporting a protected value exceeding 118 million CZK for 2025. Statistics suggest that perpetrators are adapting to control mechanisms and shifting from primitive forms of fraud to more sophisticated schemes that target higher insurance payouts. Investigation teams in 2025 recorded an increase in suspicious activities not only in traditional sectors but also in new insurance segments.
Car insurance dominance and opportunistic policy arrangement
The motor vehicle insurance sector continues to represent the majority share (over 50%) of the total volume of investigated cases. However, instead of staged traffic accidents, the issue of opportunistic policy arrangement is coming to the forefront ex post.
Fraud prevention specialists last year dealt with a number of cases of so-called backdating of an insured event. An illustrative example is a case where a subject arranged comprehensive insurance online within hours after the actual occurrence of a damage event (e.g., vehicle damage while parking). The perpetrator relied on an automated acceptance process without a physical vehicle inspection. However, forensic analysis of metadata from photographic documentation and confrontation with CCTV footage from the scene proved a temporal discrepancy between the occurrence of the damage and the start of the insurance coverage.
Veterinary care as a high-risk segment
With the growing penetration of pet insurance, the incidence of attempted insurance fraud in this area is also rising. Investigation units are increasingly identifying attempts to claim reimbursement for expensive treatment for animals with pre-existing conditions.
A typical modus operandi is the concealment of a chronic illness when concluding a contract. In 2025, a case was recorded where a client claimed reimbursement for hip dysplasia surgery for a dog, asserting that the problems arose from an injury. However, the requested veterinary history proved that the degenerative disease had been diagnosed a year before the insurance policy began. Such conduct is classified as providing false information for the purpose of unjust enrichment.
Digital Fraud: Manipulation of Medical Documentation
In the life and accident insurance segment, there's a growing trend of digital manipulation of documents. Both organized groups and individuals are using graphic software to falsify medical reports.
In 2025, detection systems uncovered a series of cases where perpetrators digitally altered treatment and diagnosis data in authentic, older medical reports. The goal was to repeatedly claim benefits for injuries that had already been compensated.
Another significant trend involves attempts to reclassify the circumstances of an injury. Perpetrators try to present injuries sustained during high-risk sports (which are excluded or require additional insurance) as common household accidents. These frauds are often debunked by thorough open-source intelligence (OSINT) analysis, especially social media profiles that capture the insured engaging in risky activities at the critical time.
Socio-Economic Profile of Perpetrators and Criminal Legal Consequences
Analysis of the client portfolio indicates a strong correlation between attempts at insurance fraud and the deteriorating financial situation of the insured. A significant portion of perpetrators consists of individuals facing enforcement proceedings or insolvency, most often middle-aged men.
It is important to emphasize that perceiving insurance fraud as a 'minor offense' is legally incorrect. It is a criminal offense with a maximum sentence of up to ten years imprisonment. In addition to criminal prosecution, the detection of fraud has long-term economic consequences for the perpetrator. A record in databases for exchanging information on suspicious circumstances (e.g., the SVIPO system) effectively prevents these individuals from entering into contractual relationships in the financial market in the future.
Insurers' success in combating this type of crime is supported by massive investments in technology. Today, machine learning algorithms and artificial intelligence enable real-time detection of anomalies and risky behavioral patterns, significantly reducing the maneuvering room for potential perpetrators.
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