Second, the scope of commercial insurance reimbursement
The situation of medical insurance is relatively simple, and the scope is still relatively wide. Many hospitals do not need to be designated. Compared with medical insurance, the scope of commercial insurance is slightly less. In addition, whether the cost of dental care belongs to the scope of reimbursement depends on the provisions of the contract.
Commercial medical insurance mainly includes hospitalization allowance type and expense reimbursement type. The previous insurance company compensated the insured for the loss during hospitalization with a fixed amount every day. This kind of product does not duplicate social security or other types of commercial medical insurance, which is a good choice.
Commercial medical insurance only reimburses the actual medical expenses incurred by the insured, and the reimbursement scope of different commercial medical insurance is different. Expense reimbursement insurance can reimburse hospitalization medical expenses, but different products have different provisions on the scope of reimbursement. Some commercial medical insurance contracts stipulate that the actual medical expenses must be reimbursed within the scope of social security reimbursement.
If compensation has been obtained from social security or other social welfare institutions, the insurance company will only pay the rest, if social security cannot be reimbursed (imported drugs, specific drugs, intensive care units, etc.). ), such commercial medical insurance can not be reimbursed, and its role is only to compensate for the part that needs to be borne by itself in proportion after social security reimbursement.
However, some commercial medical insurance stipulates that as long as the actual and reasonable expenses are incurred, the insurance company can make compensation in proportion or after a certain deductible.
Extended data
Classification of commercial medical insurance
Commercial medical insurance is divided into reimbursement medical insurance and fixed payment medical insurance according to the nature of insurance payment.
Reimbursement medical insurance is based on medical expenses caused by accidents or diseases, and the insurance company deducts the amount paid by social security according to the items and proportions agreed in the contract.
Common reimbursement medical insurance includes inpatient medical insurance and outpatient medical insurance. The content of reimbursement of hospitalization medical insurance is generally the daily hospitalization expenses, the doctor's treatment expenses during hospitalization, the expenses of using hospital equipment, the operation expenses and the medical expenses. In order to control unnecessary long-term hospitalization, this kind of insurance generally stipulates that the insurer is only responsible for a certain proportion (such as 80%) of the total cost.
The other is outpatient medical insurance, that is, according to the contract, outpatient medical treatment and medical expenses are reimbursed. Consumers should pay attention to the fact that insurance companies usually set deductibles for reimbursement medical insurance. For example, the absolute deductible stipulated in the contract is 100 yuan, and the loss is below 100 yuan, and the insurance company will not compensate; If the loss exceeds 100 yuan, the excess shall be compensated.
Reimbursement medical insurance is divided into one-year insurance and term insurance according to the insurance period, each of which has its own advantages and disadvantages. The original insured can flexibly choose the year of insurance, with high financial freedom. However, there are many regulations on the underwriting and renewal of such products. For example, for the insured over 40 years old, the physical examination standard will be stricter than that of young people, while for the insured over 50 years old, almost all require physical examination;
In addition, the insured is healthy when he is young and can almost renew his insurance, but for middle-aged and elderly people, especially those with multiple diseases and claims records, the insurance company may refuse to renew his insurance or increase the premium.
Fixed payment medical insurance refers to the medical insurance in which the insurance company pays insurance money to the insured by time, by day or by project according to the standards agreed in the contract, and the amount of claims has nothing to do with the actual medical expenses.
Generally, the fixed-rate medical insurance will be expressed in the terms of subsidy or subsidy, which is characterized by the fact that the insurance premium paid is not necessarily related to the actual expenditure. It's only related to the quantity you buy. For example, the hospitalization subsidy you bought is 100 yuan/day, so no matter how much you actually spend on hospitalization, the insurance company is only responsible for the compensation of 100 yuan per day, and nothing else is responsible.
Baidu encyclopedia-commercial medical insurance