1, the injury must be caused by work or study;
2, the injury needs to be treated in a hospital, and relevant medical certificates and lists of expenses;
3, the injury belongs to the medical insurance coverage of the disease or project, such as fractures, sprains and so on.
Medicare reimbursement conditions:
1, to confirm the identity of the insurance: in the medical treatment, you need to confirm that you have participated in the local health insurance, you can through the social security card, medical insurance certificate and other ways to confirm;
2, the type of medical treatment: medical insurance will only be reimbursed for the therapeutic medical behavior, such as outpatient, hospitalization, surgery, checkups and so on. Some cosmetic medical practices, such as cosmetic dentistry and plastic surgery, are usually not covered by health insurance;
3. Medical expenses: Health insurance will only reimburse the medical expenses that meet the requirements, such as diagnosis and treatment costs, drug costs, examination fees, and surgical fees. The medical insurance will not reimburse you for any out-of-pocket expenses.
4. Hospital qualifications: The medical insurance will only reimburse you for medical expenses incurred by legally operated medical institutions, such as public hospitals, qualified private hospitals, etc. The medical insurance will not reimburse you for any out-of-pocket expenses incurred by you. If you are not a legitimate medical institution or clinic, you will not be reimbursed by the medical insurance.
In summary, the scope and percentage of reimbursement varies, depending on the local health insurance policy. Meanwhile, if the injury is caused by personal reasons, such as playing high-risk sports privately, the medical insurance may not reimburse you.
Legal basis:
Article 28 of the Social Insurance Law of the People's Republic of China
Medical expenses that are in line with the basic medical insurance drug catalog, diagnostic and therapeutic items, standards of medical service facilities, as well as those for emergencies and salvages, shall be paid from the basic medical insurance fund in accordance with state regulations.
Article 29
The portion of the medical expenses of insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and the medical institutions and drug business units.
The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.