The insured pursues special surgical treatment, and the insurance liability should still be distinguished for the combined medical behavior.
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2022.11.25
Foreword
Basic case
Luo took himself as the insured and took out one-year medical insurance with Insurance Company A through the Internet on November 3, 2017. Insurance Company A approved the underwriting and issued the insurance contract. The insurance contract stipulates that the annual deductible is 10000 yuan, and the compensation ratio is 100 when social security is available. The hospital for treatment is limited to the general department (excluding special medical care, foreign guest medical care and cadre ward) of public hospitals of Grade II or above (including Grade II) legally operated in the People's Republic of China (except Hong Kong, Macao and Taiwan regions), it does not include nursing homes, nursing homes, rehabilitation centres, alcohol or drug rehabilitation centres, psychiatric treatment centres and combined hospitals or combined wards of secondary or tertiary hospitals without corresponding medical staff or equipment. After the expiration of the insurance contract, Luo will continue to insure and pay the insurance premium. The valid period of the latest insurance contract is from November 3, 2019 to November 3, 2020.
The insured Luo Moumou went to Huizhou Central People's Hospital and the Third People's Hospital for consultation due to eye diseases, and both replied that he could not perform "femtosecond" eye surgery for the time being. On December 19, 2019, Luo chose Huizhou Eye Hospital, which can perform "femtosecond" eye surgery. According to the diagnosis of the eye hospital, Luo's condition is "binocular complicated cataract, binocular ametropia, binocular high myopia fundus changes, and right eye retinal reattachment". According to the hospital's arrangement, Luo Moumou successively performed full femtosecond laser surgery on his left eye and right eye. On December 20, 2019, Luo Moumou underwent left eye surgery, under surface anesthesia, "left eye femtosecond assisted cataract phacoemulsification + intraocular lens implantation", and was discharged the next day after the operation. Luo Moumou's medical expenses for left eye surgery are 35514.73 yuan, of which the social security reimbursement amount is 6935.88 yuan and the self-paid amount is 28578.85 yuan. On January 21, 2020, Luo was admitted to the hospital for right eye surgery, and the right eye was discharged the day after the operation under surface anesthesia, "right eye femtosecond assisted cataract phacoemulsification + intraocular lens implantation. Luo Moumou's medical expenses for right eye surgery are 42566.95 yuan, of which the social security reimbursement amount is 5725.28 yuan and the self-paid amount is 36841.67 yuan.
Referee's point of view
The court found that the ophthalmology hospital where the plaintiff Luo Moumou sought medical treatment was approved by the Huizhou Health and Family Planning Commission on April 3, 2014. The business nature is for-profit, and the hospital level is level II. The approval is valid until April 3, 2016. The Huizhou Municipal Health Bureau issued a letter on April 1, 2019 that the eye hospital is now an eye hospital that has not implemented hierarchical management. Because the hospital voluntarily charges the relevant medical service items involving medical insurance payment with reference to the medical service prices of the secondary hospitals of the local public hospitals, which meets the relevant policy requirements, the Huizhou Health Bureau supports it within the scope of its authority.
The court held that the plaintiff Luo Moumou confirmed in the complaint that the eye hospital he visited was not a public hospital, and the fact was clear. The insurance contract has a very clear agreement on hospitals, and the scope of medical treatment is limited to public hospitals at or above the second level. The defendant explained that the fee management of public hospitals is more standardized, and the practice of the insurance industry is to select public hospitals with standardized fees. From the contract provisions themselves, there is no obvious violation of the law. Theoretically speaking, according to the cognition of ordinary people, the medical level of public hospitals is not generally lower than that of private hospitals. For diseases that can be cured by private hospitals, the medical level of public hospitals can also be cured. The basic principle of insurance is to reduce losses and protect basic needs. The reason why the plaintiff chose private hospital treatment in this case is to pursue special medical services and enjoy better medical services, which exceeds the needs of insurance and should be borne by the plaintiff. Medical expenses.
Case assessment
1.The agreement in the insurance contract for treatment in the designated hospital is valid.On March 17, 2009, the Central Committee of the Communist Party of China and the State Council issued the "Opinions on Deepening the Reform of the Medical and Health System", proposing to establish a medical and health system with Chinese characteristics, and gradually realize the development goal of everyone enjoying basic medical and health services and improving the health of the whole people.Since then, China's medical system has entered a leap-forward development.Especially since the 18th National Congress of the Communist Party of China, the development of medical security has entered a new stage, and the reform of universal medical insurance has been advanced in depth, achieving full coverage of county-level, township-level, and village-level medical and health institutions. my country has established a basic medical security system covering the whole people.The Several Opinions of the State Council on Accelerating the Development of Commercial Health Insurance (No. 50 [2014] of the State Council) pointed out that all kinds of medical institutions are encouraged to cooperate with commercial insurance institutions and become designated medical institutions of commercial insurance institutions.In areas where major illness insurance for urban and rural residents and various medical insurance handling services are carried out, strengthen the supervision, control and evaluation of medical expenses of designated medical institutions by commercial insurance institutions.
The setting of medical institutions at different levels gives insurance companies more freedom in the choice of designated hospitals. However, based on interest-driven, it is possible to defraud insurance money, such as hanging bed for hospitalization, falsely prescribe drugs, and falsify and alter medical records. Insurance companies often sign contracts with trusted hospitals and agree with the insured in the insurance contract to see a hospital, and hand over the underwriting risk to the designated hospital to effectively arrange the reasonable medical behavior of the insured. In this regard, according to Article 20 of the Interpretation (III) of the Supreme People's Court on Several Issues Concerning the Application of the the People's Republic of China Insurance Law (Fa Shi [2015] No. 21): "If the insurer refuses to pay insurance money on the grounds that the insured has not received medical treatment in the medical service institution stipulated in the insurance contract, the people's court shall support it, except where the insured must seek medical treatment immediately due to emergency."
2.The medical expenses arising from the provision of full femtosecond laser surgery special medical treatment in designated hospitals should be classified and treated. Full femtosecond laser surgery has been introduced from abroad since 2010. At present, there are many hospitals that can perform this operation in the Shenzhen Special Economic Zone, such as Peking University Shenzhen Hospital and Shenzhen Eye Hospital. In addition, Huizhou Central People's Hospital will be able to perform such operations from March 2021 by introducing two sets of high-precision systems-Zeiss VisuMax full femtosecond laser surgery system and MEL90 excimer laser surgery system. According to the function and task of the hospital, the above-mentioned hospitals belong to the third-class A public hospitals, which meet the requirements of the designated hospital terms stipulated in the insurance contract. For the insured, they can choose to go to a designated hospital outside Huizhou, the city where they live, for surgery, or choose to postpone myopia surgery. The insurance company refused to pay compensation on the grounds that the insured did not go to the designated hospital, which is difficult to convince the insured.
The disease suffered by the insured Luo in this case belongs to ultra-high myopia combined with cataract. The implementation of "femtosecond assisted cataract phacoemulsification and intraocular lens implantation" effectively solves the problem of cataract and ultra-high myopia through one operation. Myopia is a kind of refractive error. Vision correction through full femtosecond laser surgery is within the scope of exemption from insurance contract liability; that is to say, the medical expenses incurred by vision correction surgery are not compensated. Except for the case of cataract diagnosed before insurance, the medical expenses incurred by the insured for cataract surgery through full femtosecond laser surgery are covered by insurance liability. Based on this, the medical expenses arising from such combined operations in designated hospitals, which fall within the scope of insurance liability, need to be further correctly distinguished.
Concluding remarks
Commercial health insurance is insurance that is paid by a commercial insurance institution for losses caused by health reasons and medical acts.According to the "Guiding Opinions of the General Office of the China Banking and Insurance Regulatory Commission on Further Enriching the Supply of Life Insurance Products" (2021 No. 107), the spirit of "continuing to standardize, simplify, and popularize product terms" should be further improved The readability, scientificity and compliance of product terms, reduce the complexity of insurance terms, and help consumers better understand and choose life insurance products.The professional, cumbersome and difficult to understand insurance terms can lead to misreading of insurance.In particular, the network insurance, but also depends on the policyholder's ability to read and understand.The implementation of the insurance prompt system is conducive to solving the contradiction between the popularity and precision of the policy.The emergence of new medical technologies and new drugs has enhanced people's cognition and confidence in the treatment of diseases. At the same time, disputes such as whether purchased targeted drugs are covered by insurance liability have also arisen.Before treatment, the insured should fully communicate and receive guidance with the insured insurance company to protect their rights and interests to a greater extent.Insurance companies accelerate the development of commercial health insurance products at different levels, carefully handle the coverage between general medical insurance and special medical insurance, and complement and form a joint force with general medical insurance products, which is conducive to meeting the diversified health protection of insurance consumers Demand is conducive to reducing disputes and promoting the healthy development of the insurance market.
