Chapter I General Provisions Article 1 These Measures are formulated in accordance with the Insurance Law of People's Republic of China (PRC) (hereinafter referred to as the Insurance Law) for the purpose of promoting the development of health insurance, standardizing the business activities of health insurance and protecting the legitimate rights and interests of the parties involved in health insurance activities.
Article 2 The term "health insurance" as mentioned in these Measures refers to the insurance that insurance companies pay insurance money for losses caused by health reasons through sickness insurance, medical insurance, disability income loss insurance and nursing insurance.
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? China Insurance Regulatory Commission? ) Supervise and manage 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.
Article 17 Where an insurance company submits short-term personal health insurance products with floating rates for approval or filing, the application materials submitted shall include the methods and scope of benchmark rates and floating rates, and shall be signed and confirmed by actuaries according to the principle of prudence.
Eighteenth short-term group health insurance products can adjust the product parameters.
Product parameters refer to the insured amount, minimum compensation amount, compensation ratio, excluded liability, liability waiting period and other matters that can be reasonably adjusted according to the specific conditions of the insured group.
Article 19 Where an insurance company submits a short-term group health insurance product with adjustable product parameters for examination and approval or filing, the application materials submitted shall include the method for adjusting the product parameters, and shall be signed and confirmed by an actuary according to the principle of prudence.
When an insurance company sells short-term group health insurance products with adjustable product parameters, it shall calculate the corresponding insurance premium rate according to the adjustment method of product parameters, and the adjustment of product parameters shall not change the rate calculation method and the basic data required for rate calculation.
If an insurance company sells short-term group health insurance products with adjustable product parameters and needs to change the rate calculation method or the basic data required for rate calculation, it shall re-submit the product for approval or filing.
Article 20 For a health insurance product containing a guarantee renewal clause, the effective time of the guarantee renewal clause shall be clearly stipulated.
For health insurance products with guaranteed renewal clauses, it is not allowed to stipulate that the insurance company has the right to adjust the insurance liability and the scope of liability exemption at the time of renewal.
For health insurance products submitted by insurance companies for examination and approval or filing, the pricing method of guarantee renewal and the calculation method of liability reserve shall be explained in the actuarial report of the products.
Article 21 An insurance company shall respect the insured's right to obtain reasonable medical services when drawing up the terms of medical insurance products, and shall not set unreasonable or contrary conditions in the terms as the conditions for paying insurance benefits.
The disease diagnosis standards agreed by insurance companies in the terms of health insurance products shall conform to the prevailing medical diagnosis standards and take into account the development trend of medical technical conditions. After the health insurance contract comes into effect, if the insured is diagnosed with a disease according to the prevailing medical diagnostic criteria, the insurance company shall not refuse to pay the insurance money on the grounds that the diagnostic criteria are inconsistent with the insurance contract.
Article 22 When designing medical insurance products with cost compensation, insurance companies must distinguish whether the insured has free medical insurance and social medical insurance, and treat them differently in terms of insurance clauses, rates and compensation amount.
Article 23 An insurance company may stipulate in its medical insurance products that it is a condition for the insured to seek medical treatment in the designated medical service institutions.
The outlets of medical service institutions designated by insurance companies shall follow the principle of convenience for the insured and reasonable management of medical expenses, guide the insured to use medical resources rationally and save medical expenses, and do a good job in propaganda and explanation of the insured and the insured.
Article 24 An insurance company shall, according to the actual payment experience of health insurance products, timely revise the rate of newly sold health insurance products, and conduct examination and approval or filing in accordance with the relevant provisions of the China Insurance Regulatory Commission.
Chapter IV Sales Management Article 25 When selling health insurance products, an insurance company shall strictly implement the insurance clauses and insurance rates that have been approved or filed.
Article 26 An insurance company selling health insurance products shall not commit any of the following acts:
(1) Selling health insurance products in medical institutions;
(2) Entrusting medical institutions or medical personnel to sell health insurance products.
Article 27 When an insurance company sells health insurance products, it shall explain the contents of the insurance contract to the applicant, and make a written notice on the following matters, which shall be signed by the applicant for confirmation:
(1) Insurance liability;
(2) Exemption from liability;
(3) The waiting period of insurance liability;
(four) the hesitation period of the insurance contract and the relevant rights and obligations of the applicant;
(five) whether to provide the guarantee renewal and the effective time of renewal;
(6) Claims procedures and claims documents;
(seven) the insurance period of each product in the combined health insurance products;
(eight) other matters stipulated by the China Insurance Regulatory Commission.
Article 28 When selling health insurance products, an insurance company shall not exaggerate the scope of insurance coverage, conceal the reasons for exemption, or mislead the insured and the insured.
If the applicant and the insured inquire about the insurance terms, such as insurance, medical treatment and diseases, the insurance company shall explain them in clear and understandable language.
Article 29 When an insurance company sells medical insurance with compensation for expenses, it shall ask the insured whether the insured enjoys free medical care, social medical insurance and other medical insurance with compensation for expenses.
An insurance company shall not induce the insured to repeatedly purchase medical insurance products with the same or similar protection functions.
Article 30 When an insurance company sells the medical insurance stipulated in Article 23 of these Measures, it shall inform the applicant of the list of medical service institutions or the qualification requirements agreed upon, and provide inquiry services.
If an insurance company adjusts the outlets of contracted medical service institutions, it shall promptly notify the applicant or the insured.
Article 31 Where an insurance company sells health insurance products without guaranteed renewal clauses in the form of additional insurance, the insurance period of the additional insurance shall not be less than that of the main insurance.
Article 32 When an insurance company sells personal medical insurance products with cost compensation, it shall pay a return visit to the applicant within the hesitation period.
If an insurance company finds that the insured is misled, it shall do a good job of explanation and clearly inform the insured of the right to terminate the insurance contract within the hesitation period.
Article 33 When an insurance company underwrites group health insurance, it shall inform each insured in writing of his participation and related rights and interests in the form of a notice.
Article 34 If the applicant cancels the group health insurance contract, the insurance company shall require the applicant to provide valid proof that the applicant has been notified to surrender, and the surrender money shall be returned to the account of the applicant's unit by bank transfer.
Chapter V Actuarial Requirements Article 35 An insurance company engaged in health insurance business shall submit the actuarial report or reserve evaluation report of the previous year in accordance with the relevant provisions of the China Insurance Regulatory Commission, and report in detail the calculation basis, method and results of the health insurance reserve and its influence on the company's solvency, which shall be signed by the actuary in accordance with the principle of prudence.
Article 36 An insurance company shall withdraw the outstanding claims reserve that has occurred and has been reported.
An insurance company shall use reasonable methods such as transaction estimation method and transaction average compensation method to prudently withdraw the outstanding claims reserves that have occurred, reported and reported.
Where an insurance company uses actuarial methods other than case-by-case estimation method to make provision for reported outstanding claims, it shall report the basic data, parameter setting and estimation method of this method in detail, and explain the source of basic data, data quality and reliability of reserve calculation results.
If the actuarial person in charge of an insurance company cannot confirm the reliability of the estimation method or the relevant business experience data is less than 3 years, it shall withdraw the outstanding claims reserve according to the amount of claims already proposed.
Article 37 For those that have occurred but have not been paid, the insurance company shall withdraw the outstanding compensation reserve that has occurred but has not been reported.
An insurance company shall, according to the risk nature and empirical data of insurance products, use at least two methods, namely, the chain ladder method, the average compensation method, the reserve progress method and the B-F method, to evaluate the outstanding loss reserve, and select the maximum value of the evaluation result to determine the best estimated value.
An insurance company shall report in detail the basic data, calculation method and parameter setting of the outstanding claims reserve, and explain the source of the basic data, the data quality and the reliability of the calculation results of the reserve.
If the actuary in charge of the insurance company judges that the data base cannot guarantee the reliability of the calculation results, or the relevant business experience data is less than 3 years, the insurance company shall withdraw the outstanding claims reserve that has occurred but has not been reported according to not less than 65,438+00% of the actual claims expenditure in the fiscal year.
Article 38 For short-term health insurance business, the insurance company shall withdraw the unexpired liability reserve.
Short-term health insurance shall use one of the following methods to extract the unexpired liability reserve:
(1) quarterly gross premium method (accrued monthly);
(2) Article 365 Gross premium method (accrued on a daily basis);
(3) According to the risk distribution, other more cautious and reasonable methods can be adopted, and the unearned liability reserve shall not be lower than the lesser of methods (1) and (2).
Article 39 The withdrawal amount of the unexpired liability reserve for short-term health insurance shall not be lower than the higher of the following two items:
(a) The balance of estimated future compensation and expenses after deducting relevant investment income;
(2) On the assessment date of liability reserve, it is assumed that all policies will be surrendered.
If the unearned liability reserve is insufficient, the premium shortage reserve shall be withdrawn to make up for the difference between the unearned liability reserve and the larger one in the preceding two items.
Fortieth long-term health insurance unearned liability reserve shall be accrued in accordance with the relevant provisions of the China Insurance Regulatory Commission.
Article 41 An insurance company shall report the results of reserve withdrawal to the China Insurance Regulatory Commission before and after reinsurance.
Chapter VI Reinsurance Management Article 42 An insurance company shall abide by the Insurance Law, the Regulations on the Management of Reinsurance Business and other relevant provisions when handling health insurance reinsurance business.
Article 43 Except for reinsurance companies and branches of foreign insurance companies, branches of insurance companies may not handle health insurance reinsurance business.
Chapter VII Legal Liability Article 44 If an insurance company violates the provisions of Article 8 of these Measures, the China Insurance Regulatory Commission shall order the insurance company to make corrections within a time limit; If it fails to make corrections within the time limit, it shall be given a warning by the China Insurance Regulatory Commission and fined 30,000 yuan.
Article 45 If an insurance company violates the relevant provisions of Articles 13 to 15 and Article 20 to 23 of these Measures, the China Insurance Regulatory Commission shall order the insurance company to stop selling the product, impose a fine of less than 30,000 yuan on the insurance company, and give a warning to the actuarial responsible person and the legal responsible person who are responsible.
Article 46 If an insurance company violates the provisions of Article 24 of these Measures, which may endanger the solvency of the insurance company, the China CIRC shall order it to stop selling the product.
Article 47 If an insurance company violates the relevant sales management provisions of these Measures, it shall be given a warning by the China Insurance Regulatory Commission and fined not more than 30,000 yuan; Give a warning to the senior managers and other directly responsible personnel who are directly responsible and impose a fine of less than 5,000 yuan.
Forty-eighth actuaries who violate the relevant actuarial provisions of these Measures shall be punished by the China Insurance Regulatory Commission in accordance with relevant laws and administrative regulations.
Article 49 Where a branch of an insurance company handles health insurance reinsurance business in violation of the provisions of Article 43 of these Measures, the China CIRC will impose a fine of not more than 30,000 yuan, and impose a fine of not more than 5,000 yuan on the senior managers and other directly responsible personnel.
Chapter VIII Supplementary Provisions Article 50 If the provisions promulgated by the China Insurance Regulatory Commission before the implementation of these Measures are inconsistent with these Measures, these Measures shall prevail.
Article 51 Before the implementation of these Measures, if an insurance company does not fully meet the conditions stipulated in these Measures, it shall meet the conditions stipulated in these Measures within the prescribed time limit. The specific measures shall be formulated separately by the China Insurance Regulatory Commission.
Article 52 The China Insurance Regulatory Commission shall be responsible for the interpretation of these Measures.
Article 53 These Measures shall come into force as of September 6, 2006.