Medical expenses include registration fee, examination fee, laboratory fee, operation fee, treatment fee, hospitalization fee, medicine fee, etc. Whether these expenses are established should be determined by combining medical records, diagnosis certificates and other relevant evidence. Please pay attention to the comments:
(1) Check whether the medical expenses are for treating injuries. Medical expenses unrelated to injury purchased by the injured person without authorization, such as treatment of other inherent diseases, are not within the scope of compensation. Has been reimbursed by the unit, should not be included in the scope of compensation.
(2) review the amount of medical expenses and determine the actual amount before the end of the debate in the court of first instance. Rehabilitation expenses, appropriate cosmetic expenses and other follow-up treatment expenses necessary for organ function recovery training can be prosecuted separately when they actually occur. However, according to the medical certificate or appraisal conclusion, the inevitable expenses can be compensated together with the medical expenses that have already occurred.
(3) Audit of specific medical expenses:
1) Generally it should be a local hospital. If it is really necessary to transfer to a foreign hospital for treatment, it needs the consent of the local hospital. Without consent, compensation is generally not allowed (this provision is open to question? Forced transfer leads to shock in the later stage of the case, which is not conducive to handling the case).
2) Medical expenses must be for treating diseases caused by trauma or injury, and medical expenses unrelated to trauma shall not be compensated (this provision is also unreasonable. When the basic disease coincides with trauma, it is often necessary to control the basic disease first and then carry out external treatment. At this time, the author thinks that the cost of treating basic diseases is reasonable.
3) Drugs purchased by the parties in medical and pharmaceutical units outside the treatment hospital must be really necessary and approved by the treatment hospital. The injured will not be compensated for buying drugs that are unnecessary for treatment. (★: It is really necessary, and it is necessary for treatment. I don't think it's necessary if it's approved by the hospital. The key depends on the purpose of buying medicine privately, often for convenience, saving money and other reasons)
4) Audit of hospitalization expenses, the premise of hospitalization is limited to the case that the injury requires hospitalization to determine the injury and surgical treatment. For those who live in high-grade wards, they should be calculated according to the cost of ordinary wards. (But the room rate does not belong to the scope of forensic clinical appraisal)
5) The expenses for inspection, diagnosis and auxiliary inspection shall be reviewed to see whether there are repeated inspections and high inspections. (This kind of appraisal conclusion often involves the relationship between patients and hospitals and should be handled with caution. )
6) Follow-up treatment costs refer to the re-treatment costs or future costs of those who have not recovered, subject to the certificates issued by effective medical institutions or the appraisal conclusions issued by relevant appraisal institutions. (The current mode of operation is: medical institutions issue certificates to appraisal institutions, and appraisal institutions will further confirm them, but appraisal institutions often stay in form without substantive examination. )
7) If the insurance contract stipulates that medical expenses are limited to the scope of medical insurance coverage, the agreement shall be understood as reasonable medical expenses. Insurance companies can review the rationality of medical expenses according to law. For the appraisal of the rationality of medical expenses, the court can hire a forensic doctor to conduct an audit according to the unanimous opinion of the parties, and the audit conclusion can be adopted as expert testimony. If the parties have different opinions on the forensic examination opinions, they may apply for forensic identification.
Second, the review matters
(1) rationality review of drug use: it is recommended to use medical insurance drugs, master the principle of symptomatic, moderate, reasonable and timely drug use, and ask the plaintiff to provide prescriptions and doctor's orders when handling, so as to avoid hitchhiking and impersonation, and at the same time facilitate cost review. There are only hospital charge invoices, and the part without medical advice should not be protected. (doctor's advice+charge invoice)
Whether to use nutritional support drugs and energy mixtures depends on the injured person's situation at that time and his physical condition after injury. If the injured person loses a lot of blood or is old and weak, nutritional support drugs can be used appropriately to promote the early recovery of the injury, and it is not appropriate to use them in large quantities in other cases.
The use of antibiotics is quite common in injuries, accounting for a large proportion of drug costs. Medical insurance drugs should follow the ladder from low to high, and the indications should be strictly controlled when they are used together, such as serious infection or unexplained mixed infection; Taking medicine for a long time may lead to drug resistance or double infection; Those drugs that need to play a synergistic role in combination medication, etc. For the combination drugs that do not meet the indications, they will not be protected, and only one of them can be considered reasonable.
At the same time, check the dosage to see whether the medication meets the conventional dosage and whether the medicine prescribed per unit time can be used up.
(2) The comprehensive inspection of instruments and equipment and the repeated inspection of expensive instruments without inspection indications are considered as unreasonable medical expenses in principle. If there are inspection indications and the repeated inspection results are negative, only the first time fee can be guaranteed. (This provision is unreasonable)
(3) Reimbursement: Common cases include skull repair, installation and internal fixation of different eyes and teeth, etc. , based on the local secondary medical level; Plastic surgery and visceral adhesion removal surgery must have the consent of the original attending doctor; Whether the scar needs to be repaired depends on whether it affects the function. If scar adhesion affects the function of joints or organs, it needs to be repaired, otherwise the expenses incurred should not be guaranteed. (This provision is unreasonable)
(4) Relationship between injury and illness: 1) Injury has nothing to do with illness. During the post-injury treatment, the treatment of injuries and medical expenses can only guarantee the injured part; 2) There is a certain relationship between injury and disease, that is, injury has a certain aggravating effect on the disease, and the treatment of injury should be completely recognized as reasonable, while the treatment expenditure for disease is usually compensated according to the approximate proportion of participation, but it does not exceed 50%; 3) Injury induces a certain disease, which is a reasonable part of the cure cost. The author thinks that the injurer should compensate 20-30% of the total amount. The reasonable compensation for the recurrence of primary disease caused by trauma should refer to the treatment of trauma-induced diseases.
Third, review methods
The calculation of medical expenses is determined according to the relevant provisions of laws and judicial interpretations, receipts of medical expenses and hospitalization expenses issued by medical institutions, and relevant evidence such as medical records and diagnosis certificates.
It should be noted that the charging voucher here is a legal voucher that conforms to the relevant national financial management norms. If it is not obtained through proper channels, the court may reject the request for medical expenses on the grounds that the evidence cannot prove the medical expenses. For example, if the parties see a doctor in a black clinic or a black drugstore, there is no legal fee voucher, and only the receipt of the agent will not have enough probative force.
Regarding the rationality of the expenses, the evidence of medical expenses mainly includes the receipt of fees from medical institutions, prescriptions, doctor's orders, diagnosis certificates of illness, etc. When determining the amount of medical expenses, we should pay special attention to the consistency of two evidences, namely, the consistency of the receipt and the prescription, and the consistency of the diagnosis and the prescription. The former means that the medical expenses should conform to the doctor's diagnosis and treatment plan, rather than the patient deciding how to buy medicine or whether to be hospitalized. The latter means that the hospital's diagnosis scheme is consistent with the patient's own situation and cannot be a minor illness. The treatment plan is obviously beyond the general medical knowledge, such as only minor injuries, but the hospital's diagnosis and treatment plan includes long-term hospitalization and repeated diagnosis of expensive equipment. , resulting in high costs, these medical expenses requests will be rejected by the court.
Medical expenses in personal injury compensation disputes are generally based on actual expenses, and the judicial interpretation stipulates: "The amount of compensation for medical expenses shall be determined according to the amount actually incurred before the end of the debate in the court of first instance. The obligee can sue separately after deducting the necessary rehabilitation expenses, appropriate cosmetic expenses and other follow-up treatment expenses of organ function recovery training. However, according to the medical certificate or appraisal conclusion, the inevitable expenses can be compensated together with the medical expenses that have already occurred. " For the follow-up medical expenses, the parties can claim according to the proof of the medical institution, or they can sue separately according to the actual expenses after the follow-up treatment. If the subsequent medical expenses are determined to be inevitable by the diagnosis certificate or appraisal conclusion, the court can directly support the litigant's claim about the later medical expenses according to the certificate.
In the litigation, if both parties dispute the rationality and necessity of medical expenses, the compensation obligor shall bear the corresponding burden of proof for the necessity and rationality of treatment. In other words, if the compensation obligor refuses to accept the medical expenses, he shall provide evidence to prove that the expenses are unreasonable and unnecessary.
In judicial practice, the common manifestations of unreasonable medical expenses mainly include the following aspects:
(1) Non-traumatic medication, and treatment after injury.
(2) The use of Hangshengsu is unreasonable. Antibiotics are often used in injury cases, and many injured people use it in excess of dosage and time limit. For minor injuries, high-grade antibiotics are used, and multiple antibiotics are used in combination;
(3) Nutritional support drugs, which are widely used while treating injuries;
(4) Long-term treatment after minor injuries;
(5) Some parties to the dispute have no obvious damage, but the chief complaint symptoms are serious, and doctors use a lot of drugs to treat them;
(6) When prosthetic limbs or other substitutes need to be installed and internal fixation needs to be used during the operation, high-grade imported ones are used illegally, such as an internal fixation intramedullary pin, which costs only two or three thousand yuan for domestic products and more than ten thousand yuan for imported ones;
(7) At present, there are more and more new high-grade examination instruments and items, and many injured people have to carry out comprehensive examinations, repeat examinations and expand medical expenses;
(eight) according to the provisions of hospitalization, transfer, expand the unreasonable expenses;
(9) Hitchhiking prescription, impersonation occurs from time to time.
For unreasonable expenses, we can consider auditing from the following aspects:
The Supreme People's Court's Opinions on Implementing the General Principles of the Civil Law of People's Republic of China (PRC) stipulates that the compensation for medical expenses should generally be based on the diagnosis certificate of the local treatment hospital and the documents of medical expenses and hospitalization expenses. Without the approval of the medical department, the cost of finding another hospital for treatment is generally not compensated, and the cost of purchasing drugs unrelated to damage compensation or treating other diseases is not compensated; (the Supreme People's Court's Opinions on Several Issues Concerning the Implementation of the General Principles of the Civil Law of People's Republic of China (PRC) (for Trial Implementation), Articles 88, 94, 1 15, 1 17, 1 18 and 6544.
Article 19 of the Supreme People's Court's Interpretation on Several Issues Concerning the Application of Laws in the Trial of Personal Injury Compensation Cases stipulates: "The medical expenses shall be determined according to the receipts of medical expenses and hospitalization expenses issued by medical institutions, combined with medical records, diagnosis certificates and other relevant evidence. If the obligor for compensation disagrees with the necessity and rationality of the treatment, he shall bear the corresponding burden of proof. " This interpretation clearly stipulates the burden of proof of the compensation obligor for the first time. However, due to the relevance of medical behavior and litigation disputes, the rationality and necessity of drug use are all professional issues, according to the provisions of Article 72 of the Civil Procedure Law, "If the people's court considers it necessary to identify specialized issues, it shall submit them to the legal appraisal department for appraisal; If there is no statutory appraisal department, it shall be appraised by the appraisal department designated by the people's court. "
Article 6 1 of the Supreme People's Court's Provisions on Evidence in Civil Proceedings stipulates: "The parties may apply to the people's court 1 or two persons with specialized knowledge to appear in court to explain the specialized issues of the case. If the people's court approves its application, the relevant expenses shall be borne by the party making the application. " -"Expert witness"
Therefore, under normal circumstances, the medical expenses related to litigation should not be completely proved by the judge. The burden of proof of the compensation obligor is not enough only by its statement, but should be completed with the help of the appraisal conclusion of the appraisal department or the testimony of expert witnesses. Although "Several Provisions of the Supreme People's Court on Evidence in Civil Proceedings" stipulates that expert witnesses can appear in court to provide expert opinions on relevant specialized issues, in practice, few experts testify on the rationality and necessity of medical expenses. It is difficult for the compensation obligor to complete the burden of proof, which often leads to the deviation between legal truth and objective truth, which is not conducive to identifying the main points and stopping disputes.
The defendant's objection method mainly combines "medical record" and "diagnosis certificate" to infer the rationality of the expenses. If the defendant has any objection to the medical expenses, he can apply to the court for appraisal of the "rationality" of the medical expenses to avoid unnecessary compensation. Therefore, the relevance, rationality and necessity of medical expenses should be examined by starting the judicial expertise procedure.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.