How to reimburse Beijing Pratt & Whitney Medical Insurance?

For example, Mr. Liu from Beijing is 50 years old and in good health. He is the insured of the basic medical insurance for urban and rural residents in Beijing. He bought Beijing Pratt & Whitney Health Insurance for himself at the cost of 195 yuan, and the policy came into effect on 1 2022. In March 2022, Mr. Liu was diagnosed with lung malignant tumor in three hospitals in Beijing and was hospitalized. The total cost of this treatment is 852,000, including 42,000 outpatient, 865,438+0,000 inpatient, 255,400 medical insurance reimbursement and 254,654.38+0,000 critical illness insurance reimbursement. The medical expenses borne by individuals are 343,400 yuan, of which one pays and the other pays * * * 14.64 yuan, and197,000 yuan is paid for himself. In addition, Mr. Liu spent 399,600 yuan on the purchase of domestic special drug Odivo, and his reimbursement expenses are as follows:

1, medical insurance clinic+hospitalization (self-pay one+self-pay two)

(146400 yuan -30400 yuan) * 80% = 92900 yuan.

2, medical insurance hospitalization expenses

( 197,000-20,000) * 70% = 123,900

3, special drug costs

(399,600-20,000) * 60% = 227,800

Insurance is the basic means of risk management (under the condition of market economy), an important pillar of financial system and social security system, and also an act of the insurer to pay insurance money to the insured when the contract conditions are met (the possible accidents agreed in the contract are responsible for the property losses caused by them, or the insured dies, is disabled, falls ill or reaches the age and time limit agreed in the contract).

Insurance is a financial arrangement to share accident losses economically, a contractual act in which one party agrees to compensate the other party for losses according to law, an integral part of the social and economic security system in society, and a basic method of risk management.

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First, there must be risks in insurance. The purpose of establishing insurance system is to deal with the occurrence of specific dangerous accidents. Without risk, there is no insurance. In order to apply the principle of large number, commercial insurance institutions generally do not underwrite such risks.

Two, insurance must give economic compensation for the losses caused by dangerous accidents. The so-called economic compensation means that this kind of compensation is not to restore the destroyed original things, nor to compensate the real things, but to make monetary compensation.

Therefore, the losses caused by accidents must be economically calculable. In life insurance, people's own value cannot be calculated, but people's labor can create value. Death and disability will lead to the loss of labor force, which will reduce the income and increase the expenditure of individuals or families. Therefore, life insurance is to make up for this economic increase in the form of economic compensation or payment, rather than ensuring people to recover their lost labor or lives.

Third, insurance must have a mutual assistance relationship. The insurance system is to allocate losses to many units to reduce the losses of the affected units. Through insurance, the insured * * * jointly pays the insurance premium, establishes an insurance compensation fund, and * * * is jointly guaranteed.

Four, the insurance payment must be reasonable. The insurance compensation fund shall be shared by the insured. In order to make everyone's burden fair and reasonable, it is necessary to calculate the contribution scientifically.