The term "sickness insurance" as mentioned in these Measures refers to the insurance in which the occurrence of diseases as stipulated in the insurance contract is the condition for payment of insurance benefits.
The term "medical insurance" as mentioned in these Measures refers to the insurance that takes the occurrence of medical behaviors agreed in the insurance contract as the condition for paying insurance benefits and provides protection for the medical expenses of the insured during medical treatment.
The term "disability income loss insurance" as mentioned in these Measures refers to the insurance that pays insurance benefits on the condition that the insured loses the ability to work due to illness or accidental injury agreed in the insurance contract, and provides protection for the insured's income reduction or interruption in a certain period of time.
The term "nursing insurance" as mentioned in these Measures refers to the insurance that pays insurance money on the condition that the daily living ability disorder agreed in the insurance contract leads to the nursing demand, and provides protection for the nursing expenses of the insured. Article 3 Health insurance is divided into long-term health insurance and short-term health insurance according to the insurance period.
Long-term health insurance refers to health insurance with an insurance period of more than one year or an insurance period of less than one year, but with a guarantee renewal clause.
Short-term health insurance refers to health insurance with an insurance period of one year or less and without a guarantee renewal clause.
The guarantee renewal clause refers to the contract that after the expiration of the previous insurance period, if the applicant applies for renewal, the insurance company must continue to underwrite the insurance at the agreed rate and the original clause. Article 4 Medical insurance is divided into cost compensation medical insurance and fixed payment medical insurance according to the nature of insurance payment.
Cost-compensated medical insurance refers to medical insurance that determines the amount of insurance money according to the actual medical expenses incurred by the insured and the agreed standards.
Fixed payment medical insurance refers to medical insurance that pays insurance benefits according to the agreed amount.
The payment amount of cost compensation medical insurance shall not exceed the actual medical expenses incurred by the insured. Article 5 China Insurance Regulatory Commission (hereinafter referred to as "China Insurance Regulatory Commission") shall supervise and administer the health insurance activities of insurance companies according to law. Article 6 These Measures shall not apply to the entrusted management services provided by insurance companies that do not bear insurance risks. Chapter II Operation and Management Article 7 Life insurance companies and health insurance companies established according to law may engage in health insurance business with the approval of the China Insurance Regulatory Commission.
Insurance companies other than those mentioned in the preceding paragraph may engage in short-term health insurance business with the approval of the China Insurance Regulatory Commission. Article 8 To operate health insurance, an insurance company shall continuously meet the following conditions:
(1) Establishing an independent accounting system for health insurance business;
(two) the establishment of health insurance actuarial system and risk management system;
(three) the establishment of health insurance underwriting system and claims system;
(four) the establishment of health insurance data management system;
(5) Establish a fully functional and relatively independent health insurance information management system;
(6) Having actuaries, underwriting personnel and underwriting personnel with relevant professional knowledge;
(seven) other conditions stipulated by the China Insurance Regulatory Commission. Article 9 An insurance company shall provide professional health insurance training to its employees engaged in underwriting, claim settlement and sales of health insurance. Article 10 An insurance company shall strengthen cooperation with medical service institutions and health management service institutions, strengthen the management of medical service costs, and supervise the rationality and necessity of medical expenses.
The cooperation between an insurance company and a medical service institution or a health management service institution shall not harm the legitimate rights and interests of the insured. Article 11 An insurance company shall attach great importance to the privacy protection of the insured and establish a health insurance customer information management and confidentiality system. Chapter III Product Management Article 12 The insurance clauses and premium rates of health insurance drawn up by insurance companies shall be submitted for approval or put on record in accordance with the relevant provisions of the China Insurance Regulatory Commission. Article 13 Where a health insurance product drawn up by an insurance company contains more than two kinds of health insurance liabilities, an actuary shall judge the main liabilities according to general actuarial principles and determine the product type according to the main liabilities. Article 14 Disease insurance products in long-term health insurance may include death insurance liability, but the amount of death compensation shall not be higher than the maximum amount of disease compensation.
Health insurance products other than those specified in the preceding paragraph do not include death insurance liability, except for death insurance liability due to illness.
Medical insurance products and disease insurance products shall not include the responsibility of survival payment. Article 15 A long-term health insurance product shall have a contract hesitation period, and the rights of the insured during the hesitation period shall be clearly defined in the insurance clauses. The hesitation period of long-term health insurance products shall not be less than 10 days. Sixteenth short-term personal health insurance products can be subject to floating rates.
Rate floating refers to the insurance company's reasonable determination of the specific insurance rate within the range of rate floating on the basis of the benchmark rate when selling products.