Health insurance is divided into sickness insurance, medical insurance and income security insurance according to insurance liability.
The diseases referred to in health insurance must meet the following three conditions:
First, it must be caused by obvious non-external reasons.
Second, it must be caused by non-congenital reasons.
Third, it must be caused by non-permanent reasons.
Divided by payment method
According to the payment method, health insurance can be divided into three types:
1, payment type, when the insured suffers from diseases or circumstances agreed in the insurance contract, the insurance company pays the insurance money to the insured according to the contract. The amount of insurance money is fixed. Once diagnosed, the insurance company will pay the insurance money in one lump sum according to the insurance amount specified in the contract. The critical illness insurance of all insurance companies belongs to the payment type.
2. Reimbursement type: the insurance company reimburses the medical expenses actually paid by the insured according to the proportion agreed in the insurance contract. Such as hospitalization medical insurance and accidental injury medical insurance. It belongs to the reimbursement type.
3. Subsidized, the insurance company pays the insurance premium according to the actual hospitalization days and surgical items of the insured. The insurance premium is generally calculated on a daily basis, and the total amount of insurance premium varies according to the number of days of hospitalization and the different surgical items. Such as hospitalization medical subsidy insurance and hospitalization peace of mind insurance. There are subsidies.
Feature editing
(1) insurance period
Except for serious diseases, most health insurance, especially medical expenses insurance, is usually a one-year short-term contract.
(2) Actuarial technology
The pricing of health insurance products mainly considers the disease rate, disability rate and disease (disability) duration. The calculation of health insurance rate is based on the loss rate of insured amount, and the unexpired liability reserve at the end of the year is generally paid according to a certain proportion of the premium income of the current year. In addition, waiting period, deductible, deductible, * * payment ratio, payment method and payment limit will also affect the final rate.
(3) Pay health insurance
Whether the principle of compensation is applicable to health insurance cannot be generalized. Expense-based health insurance applies this principle and is a compensatory payment. However, the fixed payment of health insurance is not applicable, and the payment of insurance benefits has nothing to do with actual losses.
(D) the particularity of business risks
Health insurance deals with injury risk, and its influencing factors are far more complicated than life insurance, and adverse selection and moral hazard are more serious. In addition, the risk of health insurance also comes from medical service providers, and the quantity and price of medical services are largely determined by them, which is difficult for insurance companies to control as payers.
(5) Cost sharing
Because health insurance is risky, difficult to control and unpredictable, in health insurance, the insurer often has many restrictions or restrictive clauses on the payment responsibility of medical insurance for diseases.
(VI) Particularity of contract terms
Health insurance does not need to specify the beneficiary, and the insured and beneficiary are often the same person.
In the health insurance contract, besides the incontestable clauses, grace period clauses and no loss clauses of general life insurance, there are also some unique clauses, such as existing conditions clauses, conversion clauses, cooperative payment clauses, medical examination clauses, deductible clauses and waiting period clauses.
(7) Except for health insurance.
The exclusions of health insurance generally include diseases, deaths and disabilities caused by war or military action, intentional suicide or attempted suicide, and diseases, disabilities, abortion and death caused by abortion.
Category editing
medical insurance
Medical insurance refers to the insurance with agreed medical expenses as the condition of payment of insurance benefits, that is, the insurance that provides medical expenses protection, which is one of the main contents of health insurance.
Medical expenses are all kinds of expenses incurred by patients in order to treat diseases. It includes not only the doctor's medical expenses and operation expenses, but also the expenses of hospitalization, nursing and hospital equipment.
Medical insurance is the abbreviation of medical expense insurance.
1. Main types of medical insurance
(1) general medical insurance
(2) Hospitalization insurance
(3) Surgery insurance
(4) Comprehensive medical insurance
2. Common clauses of medical insurance
(1) deductible clause
There are generally three kinds of deductibles: one is the deductible for a single indemnity, aiming at the amount of each indemnity; The second is the annual deductible, which is paid after exceeding a certain amount according to the total annual compensation; The third is the collective deductible, which is aimed at group insurance.
(2) Proportional payment clause
Or * * * guarantee proportion clause. In most health insurance contracts, the insurer pays the medical insurance premium in proportion, that is, the part of the medical expenses exceeding the deductible is paid by the insurer and the insured in proportion.
Proportional payment can be fixed proportion payment or progressive proportion payment.
(3) payment limit clause
Insurers generally have a maximum payment limit for medical insurance premiums to control the total expenditure level.
sickness insurance
Sickness insurance refers to insurance with illness as the condition of payment of insurance benefits. Usually, the insurance amount of this kind of policy is relatively large, and the payment method is generally to pay the insurance amount in one lump sum immediately after the diagnosis of a special disease.
1. Basic characteristics of sickness insurance
(1) Individuals can apply for sickness insurance at will. As an independent insurance, it does not need to be attached to other insurance.
(2) Sickness insurance clauses generally stipulate a waiting period or observation period, and the insurance policy will take effect after the observation period.
(3) It is highly effective to provide the insured with disease protection.
(4) The insurance period is long.
(5) The insurance premium can be paid in installments or in one lump sum.
2. critical illness insurance
The diseases covered by critical illness insurance generally include myocardial infarction, coronary artery bypass surgery, cancer, stroke, uremia, severe burns, fulminant hepatitis, paralysis, important organ transplantation, aortic surgery and so on.
(1) by insurance period
① Regular critical illness insurance.
② Lifelong critical illness insurance.
(2) According to the form of payment
According to the payment form, there are five kinds of critical illness insurance: advance payment, additional payment, independent main insurance, proportional payment and repurchase.
Income security insurance
Income security insurance refers to insurance with the condition that income is interrupted or reduced due to accidental injury or illness. Specifically, it refers to a kind of health insurance in which the insurer pays the insurance money in installments within a certain period of time when the insured is disabled and unable to work due to illness or accidental injury.
1. The meaning of income security insurance
Insurance that provides compensation for income loss when the insured can't continue to work after disability, illness or accidental injury is income-guaranteed insurance.
Income security insurance can generally be divided into two types, one is to compensate for the loss of income caused by injury, and the other is to compensate for the loss of income caused by disability caused by illness.
(1) payment method
The payment of income security insurance is generally monthly or weekly compensation, and the same amount of income compensation can be provided monthly or weekly.
Disability income insurance should be related to the income level of the insured before disability. When determining the maximum limit, the insurance company needs to consider the following income of the insured: ① normal labor income before tax; ② Non-labor income; ③ Other sources of income during the period of disability; ④ Applicable income tax rate.
Income-guaranteed insurance can not only pay insurance money when the insured is totally disabled, but also provide other guarantees, including disability or partial disability insurance money payment, future increase insurance amount payment, living expenses adjustment payment, disability exemption premium clause, transplant operation insurance money payment, non-disability injury payment and accidental death payment. These fringe benefits are obtained by paying extra premiums as special terms.
(2) Term of payment
The payment period is the longest time for income-guaranteed policies to pay insurance benefits, which can be short-term or long-term, so there are two forms of short-term disability and long-term disability. Short-term compensation is to compensate for the loss of income before physical recovery, while long-term compensation provides for a longer payment period, generally to compensate the income of all disabled insured who cannot return to work.
(3) Exemption period
Also known as waiting period or postponement period. It means that there is no insurance money for a period of time after the start of disability, that is, a period of time before disability, similar to the exemption period or deductible in medical expense insurance, during which no compensation is given.
2. Definition of disability
Disability refers to the fixed symptoms left on the human body due to injuries and other reasons, which affect normal life and work ability. Usually the causes of disability are congenital disability, acquired disease and accidental injury. Income-guaranteed insurance does not pay insurance money for congenital disability, and stipulates that insurance money can only be paid if it meets the definition of total disability stipulated in the policy.
(1) completely disabled.
Total disability generally refers to permanent loss of all working ability and inability to participate in work (original job or any new job) to obtain wage income.
The total amount of disability payment is generally less than the income before disability, which is often 75%~80% of the original income.
(2) Partial disability
Relative to the definition of total disability, partial disability refers to partial loss of working ability. If we regard total disability as the total loss of income, then partial disability means that the insured can still engage in other gainful occupations, and the insurer will pay part of the total disability.
Partial disability pension = total disability pension × (income before disability-income after disability)/income before disability.
(3) Other payment methods
Income compensation insurance is an effective compensation for the insured's income loss, which usually has different types due to different situations.
Long-term care insurance
Long-term care insurance is a health insurance that provides compensation for the cost of nursing services for the insured who need long-term care due to old age, illness or disability.
The insurance scope of long-term care insurance is divided into four levels: medical staff care, intermediate care, nursing care and home care, but the early long-term care insurance products did not include home care.
A typical long-term care policy requires the insured not to complete two of the following five activities: ① eating; 2 take a bath; 3 dressing; 4 go to the toilet; ⑤ Move. In addition, patients with cognitive impairment such as Alzheimer's disease usually need long-term care, but they can carry out some daily activities. In order to solve this contradiction, all long-term care insurance covers Alzheimer's disease, Akimi's disease and other mental disorders.
There are several different options for the payment period of long-term care insurance, such as one year, several years and life, and there are also many exemption periods, such as 20 days, 30 days, 60 days, 90 days, 100 days or 80 days. The longer the exemption period, the lower the premium.
The premium of long-term care insurance is usually flat, and it is also increased regularly every year or every period. The premium paid each year varies greatly due to conditions such as age, waiting period and amount of insurance. Generally, there is a premium exemption guarantee, that is, the insurer is exempted from paying the premium 60 days, 90 days or 180 days after the insurer begins to perform the insurance payment responsibility.
In addition, all long-term care insurance is guaranteed to be renewed.
Finally, long-term care insurance also has a no-loss clause.
Hope to adopt
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.