1
I
摘要
近年来，随着大众保险意识的增强，因而保险行业急速发展，保险公司如雨
后春笋般大量兴起。经营性质也从国有逐步发展到国有、国企合营、企业自营等
形式共同存在。从投保内容上看，随着经济生活的不断丰富，保险业务的内容也
在不断拓展延伸，各保险公司不断推出新险种，以适应客户不断增长的需求。针
对不同险种，保险公司都有一套与之相配的理赔流程，因而保险流程的规划与制
定就尤为重要，这关系到保险公司的风险与收益。在日后保险事故发生时，保险
公司要按照投保时合同上的约定承担理赔的责任。而对于保险公司来说，其中很
重要的风险管控表现在理赔业务流程上。如果理赔业务的环节不能够得到很好的
监控和管制，那么，在推进保险行业迅速发展的路上会多了很多后顾之忧。由于
理赔业务环节存在业务量大、经办人数多、要求不统一、监管体制不完善的特点，
很多理赔定损人员可能会在不违反规定的情况下，寻找制度的管理漏洞，利用漏
洞建立起理赔业务流程的灰色地带，帮助投保人在一定程度上超额定损，甚至存
在骗保的情况。因而对保险理赔业务的研究就有着极大的必要性
本文在研究了风险管理理论和理赔业务流程的基础上，应用案例分析法将PA
保险公司的理赔业务流程再造理论与保险业的风险管理理论相结合。分析了PA保
险公司的理赔流程的不足之处和风险管理中存在的问题。根据流程再造的相关理
论，从事前预警的再造、事中控制系统的再造、事后监督系统的再造等方面提出
了完善PA保险公司风险管理的具体措施
关键词：风险管理，PA保险公司，理赔业务流程再造
II
Abstract
This year, with the increasing awareness of public insurance, the insurance industry is booming
and insurance companies are springing up like mushrooms.The nature of operation also gradually
developed from the state - owned to the state - owned joint venture self - management and other
forms of common existence.Look from the insured content, with the enrichment of economic life,
the contents of the insurance business is no longer expanding, each insurance company continuously
introduce new risks, to meet the growing demand of customers.For different types of insurance,
insurance companies have a set of matching claims process, so the planning and formulation of
insurance process is particularly important, which relates to the risks and benefits of insurance
companies.When the insurance accident happens in the future, the insurance company shall bear the
liability of settlement of claims in accordance with the agreement in the contract at the time of
insurance.In the case of insurance companies, the important risk control is reflected in the claims
business process.If the link of claims business is not well monitored and controlled, there will be a
lot of worries on the way to promote the rapid development of insurance industry.Due to the fact that
there is a large number of business operators in the claim business, there are many requirements for
the imperfect supervision system,A lot of claims loss personnel may find the management loopholes
of the system without violating the regulations, and use the loopholes to establish the gray area of the
settlement business process.It is necessary to help policy-holder to overcompensate, or even cheat,
so that the research on insurance claims business is very necessary.
In this paper, after studying the risk management theory and adjustments on the basis of
business process, use case analysis to the PA insurance company claims business process
reengineering theory combined with theory of risk management of insurance industry.This paper
analyzes the shortcomings of the claims settlement process of PA insurance company and the
problems in risk management.According to the related theory of process reengineering, the specific
measures to improve the risk management of PA insurance company are put forward in this paper.
Key words: Risk management, PA insurance company, Reengineering the claims business
process
III
目录
第一章绪论 ........ 1
1.1 研究背景及意义 ........... 1
1.1.1 研究背景 ........... 1
1.1.2 研究意义 ........... 2
1.2 文献综述 ..... 2
1.2.1 国外研究文献 ....... 2
1.2.2 国内研究文献 ....... 4
1.2.3 国内外研究文献综述 . 6
1.3 研究的思路和方法 ......... 6
1.3.1 研究思路 ........... 6
1.3.2 研究方法 ........... 7
1.4 本文研究的主要内容与结构 . 8
1.4.1 研究的主要内容 ..... 8
1.4.2 本文研究结构 ....... 9
第二章相关概念与理论 ......... 11
2.1 风险管理相关理论 ........ 11
2.1.1 风险的定义 ........ 11
2.1.2 风险管理的概念 .... 11
2.1.3 保险业风险管理的目标 .......... 12
2.1.4 保险业风险管理的原则 .......... 13
2.1.5 保险业风险管理的特点 .......... 14
2.2 业务流程再造理论 ........ 15
2.2.1 业务流程再造理论的动因和定义 .. 15
2.2.2 业务流程再造理论的原则 ........ 15
2.2.3 业务流程再造的过程16
2.2.4 业务流程再造的特点17
第三章PA保险公司理赔业务流程存在的风险及原因 ......... 18
3.1 PA保险公司的运营模式现状18
3.1.1 PA保险公司概况 .... 18。