The exclusions of health insurance are as follows:
The insured is sick or pregnant when signing the insurance contract;
Unless otherwise provided by law, the insured intentionally commits suicide or attempted suicide, resulting in illness, disability or death;
The insured suffers from illness, disability, abortion or death due to intentional abortion.
Exclusion liability of accidental injury insurance contract
Intentional or gross negligence of the insured;
Riot, civil strife, rebellion or any act of war;
Any criminal act or resisting arrest;
Pregnancy, abortion or childbirth;
Mental illness, alcoholism, drug abuse, unlicensed or drunk driving;
Non-therapeutic surgery (except for accidental injury);
General dental surgery (except those caused by accidental injuries);
When signing the insurance contract, the insured has been sick or injured;
Acquired immunodeficiency syndrome (AIDS).
Second, how to claim for health insurance
The steps of health insurance claim are as follows:
(1) Apply for claim settlement
Applicant: including the insured, the beneficiary and their entrusted agents, and the entrusted agents must hold the power of attorney.
Report the case to the insurance company in time: the insured shall notify the insurance company in time after knowing the occurrence of the insurance accident (specifically stipulated in the insurance clauses), and the insured or beneficiary of health insurance shall be extinguished if they fail to exercise their right to claim insurance money from the insurer for two years from the date of knowing the occurrence of the insurance accident.
(2) claim review
1, medical insurance is a kind of loss compensation insurance, in addition to the fixed medical insurance, after a person insured a variety of medical insurance, the compensation can be calculated separately, but the total amount of compensation should be within the insured amount and cannot exceed the actual medical expenses. Therefore, the original documents of medical expenses must be provided when making claims; Only when the insured's medical expenses have been borne by others and the insurance company needs to bear the difference can it accept a copy of the medical expense bill, but the original must be checked.
2. If the insurance clauses stipulate the observation period (also called "waiting period" and "exemption period"), the insurance liability will not begin until the end of the observation period.
3. To apply for insurance compensation, the name of the disease diagnosed by the doctor, the date of initial diagnosis, the hospital and its address and telephone number, and the identity of the doctor (social security, at their own expense) should be reviewed; Details of the accidental injury; Appraisal or opinions of relevant departments;
4. The beneficiary shall be the insured himself, and shall not accept the designation or change of the insured without the consent of the insured;
5. When the applicant or the insured is a doctor, no medical certificate or similar certificate shall be issued for the insured;
6. Hospitals refer to medical institutions that have obtained valid licenses in accordance with health management regulations, excluding institutions that do not directly treat patients, such as rest, detoxification, nursing and pension;
7. According to the exemption clause, the insured shall not be liable for the treatment expenses of diseases or injuries caused by intentional acts, criminal acts, drug abuse or use of narcotic drugs;
8. Prevent the insured from pretending to be ill and escaping from work to defraud the payment of medical expenses.
9. Pay attention to the following suspicious signs: the insured has not truthfully informed the job position, income, employer and work experience, or the employment record is unclear and inconsistent; The amount of daily medical payment is not commensurate with the financial situation of the insured; The frequency of claims by the insured's family members is too high; The hospitalization days are too long, and medical measures are too expensive and unnecessary; When applying for claims, the cause of the accident is unknown, and the doctor can only make a diagnosis according to the insured's self-report or other subjective information, especially in the identification of the cause of disability; Apply for claims with foreign hospitalization certificate; An insurance accident occurs shortly after the policy comes into effect, or claims are applied for at the end of the year when the policy expires; The reasons for claims are difficult to find, such as low back pain and headache; In disability insurance, the insured has been identified as incapacitated but still working; The application documents are altered or forged, or the information that has been rejected for compensation is changed to claim again.
(3) Payment of claims
If the application documents are verified to be correct, the insurance company shall pay the insurance premium in time after receiving all the application documents (the statutory time limit is 10 days, or as agreed in the insurance contract), and bear the overdue interest for overdue payment. The scope of payment refers to the expenses that should be borne by the insured according to the provisions of social insurance, and the expenses that do not belong to or exceed the scope of social insurance payment shall be subject to the insurance clauses.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.