Health Insurance Management

Original Language Title: 健康保险管理办法

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(August 7, 2006, China insurance regulatory Commission announced 2006 8th as of September 1, 2006) Chapter I General provisions article in order to promote the development of health insurance, regulate the operation of health insurance, protect the legitimate rights and interests of health insurance the parties, in accordance with the People's Republic of China insurance (hereinafter referred to as the Insurance Act), these measures are formulated.
    Article health insurance in these measures, through sickness insurance refers to insurance companies, health insurance, disability income insurance and care insurance for loss insurance insurance due to health reasons.
    Sickness insurance in these measures refers to the insurance contract the occurrence of diseases for insurance insurance conditions.
    Medical insurance in these measures refers to the insurance contract for payment of medical insurance benefits, for the medical treatment of the insured period of insurance of medical expenses protection.
    Disability income insurance mentioned in these measures refers to the insurance contract disease or accidental injury results in incapacity for work to pay the insurance conditions, for the insured person during a certain period income reduction or interruption in the provision of guarantee insurance.
    Care insurance in these measures refers to the insurance contract conditions of daily living barrier required to trigger payment of insurance, guarantee insurance for nursing expenses of the insured.
    Article health insurance according to the insurance period is divided into long term health insurance and short-term health insurance.
    Long-term health insurance refers to insurance or the insurance period is not more than one year more than one year but guaranteed to renew provisions of the health insurance.
    Short term health insurance refers to insurance periods in one year and one year and are not guaranteed to renew provisions of the health insurance.
    Guaranteed renewal refers to the terms, after the expiry of the previous period of insurance, the insured submit a renewal application, the insurance company must be in accordance with the provisions of contract rates and continue to underwrite the contract.
    Article fourth medical insurance according to nature of insurance payments are classified fee compensation-medical insurance and fixed payment of medical insurance.
    Refers to reimbursement of medical insurance, the insured medical expenses actually incurred, the standard insurance amount determined in accordance with the contract of medical insurance.
    Scale refers to the payment of medical insurance, the agreed amount of insurance medical insurance.
    Cost reimbursement for medical insurance payments shall not exceed the insured amount of medical expenses actually incurred.
    Fifth, China insurance regulatory Commission (hereinafter "CIRC") in accordance with the supervision and management of the activities of insurance companies health insurance.
    Sixth insurance company does not bear the insurance risk management services, these measures are not applicable.
    Chapter II management article seventh life insurance companies, health insurance companies established according to law, approved by the China insurance regulatory Commission, could run a health insurance business.
    Insurance companies other than those stipulated in the preceding paragraph, approved by the China insurance regulatory Commission, could run a short-term health insurance.
    Eighth article insurance company business health insurance, should continued has following conditions: (a) established health insurance business separate accounting system; (ii) established health insurance fine is system and risk management system; (three) established health insurance nuclear insurance system and claims system; (four) established health insurance data management system; (five) established function full, and relative independent of health insurance information management system; (six) equipped with has related expertise of fine is personnel, and nuclear insurance personnel and nuclear lost personnel;
    (VII) other conditions stipulated by the Circ.
    Nineth insurance company shall engage in insurance underwriting, claims processing, and sales of health insurance professional training of the work force.
    Article tenth insurance company reimbursement insurance, should strengthen cooperation with the health services and health management services, strengthen the management of the cost of medical services, supervision and medical expenses of reasonability and necessity.
    Insurance companies and health-care institutions and health management service cooperation between the institutions, shall be without prejudice to the legitimate rights and interests of the insured.
    11th insurance company shall attach great importance to the privacy protection of the insured, health insurance and confidentiality of customer information management systems.
    Article 12th chapter product management develop health insurance insurance clauses and premium rates shall be in accordance with the relevant provisions of the China insurance regulatory Commission submitted for approval or for the record.
    13th insurance company proposed health product contains two or more health care liability, should be determined by actuarial liability in accordance with the General principles of actuarial judgment primary responsibility and primary responsibility for identifying product types.
    14th in long-term health insurance health insurance products, you can include death insurance, death benefit amount may not be higher than diseases maximum benefit amount.
    Health insurance products other than those provided for in the preceding paragraph shall not contain death insurance, death insurance, except for liability due to disease.
    Medical insurance products liability insurance products shall not contain survival and disease. 15th long-term health insurance product should hesitate to set contract and insurance policyholders within the waiting period specified in the terms of rights.
    The hesitation of health insurance products for a long time period of not less than 10 days.
    16th short-term rates for individual health insurance products can be floating.
    Floating rate refers to insurance companies sell products, benchmark rates on the basis, in the context of floating rates, determines the specific premium rates.
    17th personal health insurance rates to floating short-term insurance products submitted for approval or for the record, submit application materials should be included in the benchmark rate, floating rate approach and scope, and confirmed by the signature of actuarial liability follow the precautionary principle.
    18th short term group health insurance products product parameters can be adjusted.
    Parameter refers to the product, in terms of insurance products can be adjusted according to specific insured groups for a reasonable amount, payment amount, payment, exclusions, liability matters, such as the period of waiting.
    Article 19th adjustable parameters of the product short term group health insurance products submitted for approval or for the record, submitted application materials should contain the product parameter adjustments, and confirmed by the signature of actuarial liability follow the precautionary principle.
    Insurance companies sell products adjustable parameters of the short term group health insurance products, ways should be adjusted according to the product parameters to calculate the corresponding premium rate, and product parameters adjusted may not change the rate calculation method and rates calculated on the basis of data.
    Insurance companies sell products adjustable parameters of the short term group health insurance products, if you need to change the rate calculation method or the rates calculated on the basis of data, the product shall be submitted for approval or for the record.
    20th contains guaranteed to renew provisions of the health insurance products should be guaranteed to renew provisions of the time expressly agreed upon.
    Guaranteed to renew health insurance products may not stipulate the terms of renewal when the insurance company has to adjust insurance liability and exclusions the scope of rights.
    Insurance companies will have guaranteed to renew provisions of the health insurance products submitted for approval or for the record, should be explained in the actuarial report guaranteed renewal pricing methods and reserve calculations.
    21st insurance companies to develop medical insurance product terms, should respect the right to receive reasonable medical service of the insured shall not be unreasonable in terms of or contrary to the General and medical standards requirement as a condition of payment of the insurance benefits. Insurance companies health insurance product in terms agreed upon diagnostic criteria shall conform to the prevailing standard of medical diagnosis of disease, and taking into account the trends of the development of health technologies.
    Health insurance after the entry into force of the contract insured according to the prevailing standard of medical diagnosis diagnosed diseases, insurance companies are allowed to the diagnostic criteria not in accordance with the insurance contract as a reason to refuse to pay the insurance.
    22nd insurance designed for cost reimbursement type medical insurance products, must distinguish between whether the insured has free medical care, social health insurance, the different situations, in insurance terms, rates, and payment amounts be treated differently.
    23rd in medical insurance products, insurance companies can contract, the insured in the designated medical service network for medical insurance conditions.
    Insurance company designated medical service networks should follow the insured, the principle of sound management of health-care costs, guide rational use of health resources and save the insured medical expenses, and the policy holder and the insured to step up publicity to explain.
    24th an insurance company should be based on actual claims experience of health insurance products, amending the new rates of health insurance products sold in a timely manner and in accordance with the relevant regulations of the China insurance regulatory Commission for approval or for the record.
    The fourth chapter 25th insurers selling health insurance products in sales management, should be strictly enforced upon approval or for the record the insurance clauses and premium rates.
    26th insurers selling health insurance products shall not be any of the following acts: (a) in the medical institutions in place for the sale of health insurance products, (ii) commissioned medical institutions or medical staff selling health insurance products. 27th article insurance company sales health insurance products, should to policyholders description insurance contract of content, and on following matters made written told, by policyholders signed confirmed: (a) insurance responsibility; (ii) responsibility from; (three) insurance responsibility waiting for period; (four) insurance contract hesitated period and policyholders related right obligations; (five) whether provides guarantee renewal and renewal effective time; (six) claims program and claims file requirements; (seven) combined health insurance products in the the products of insurance during; (eight)
    Other inform matters stipulated by the Circ.
    28th an insurance company selling health insurance products, insurance coverage shall not exaggerated, not withholding the exemption from liability shall not be misleading policyholders and insured persons. Policy holder and the insured on insurance provisions in the insurance, medical and disease terminology question, the insurance company should be explained in clear and understandable language.

    29th insurance company sales cost reimbursement for medical insurance, should be to the applicant asking if the insured has free medical care, social health insurance compensation of medical insurance and other costs.
    Insurers could not induce repeat purchase of insured protection identical or similar compensation-medical insurance products.
    30th medical insurance insurance companies sell the way article 23rd, shall be notified to the applicant agreed to list of medical services or qualifications, and provide query service.
    Insurance companies adjust the agreed network of health care institutions, it shall promptly notify the applicant or insured.
    31st an insurance company in the form of additional insurance selling health insurance products which are not guaranteed to renew provisions, additional health insurance term shall not be less than the main risk insurance term insurance.
    Article 32nd-insurance sales compensation for private medical insurance products, should hesitate to visit the insured during the period.
    Insurance company found the applicant to be misled, it should be explained, and clearly inform the insured's right to terminate the contract within the waiting period.
    Article 33rd insurance group health insurance, each insured shall be notified by notice in writing in the form of its insured, and related interests.
    Article 34th insured group health insurance contract is terminated, the insurance company shall notify the insured require the applicant to provide valid proof of the surrender, surrender the gold unit accounts by bank transfer should be returned to the applicant.
    Actuarial requirements article 35th of the fifth chapter of the health insurance business insurance company shall, in accordance with the relevant regulations of the China insurance regulatory Commission last year actuarial report or reserve evaluation report, including detailed reporting of health insurance reserve calculation of foundations, methods, results and the impact on the solvency of the company and confirmed by the signature of actuarial liability follow the precautionary principle.
    Article 36th insurance accident has happened and has made claims, insurance companies pending claims, insurers reported outstanding claims reserve shall be drawn to have occurred.
    Insurance companies should be taken case-by-case method, payment method and other methods of reasonable care extraction has reported outstanding claims reserve.
    Insurance company if taken outside the method of case-by-case report on the actuarial method of calculation has had an outstanding loss reserve, should report in detail the method of the underlying data, parameter setting and estimation methods, and the underlying data sources, data quality, and reserve the reliability of the result.
    Insurance actuarial liability could not confirm an estimated reliability of or less than 3 years of related business experience data, amount of claims shall have extracted has reported outstanding claims reserve.
    37th insurance accident has happened, but not for compensation or payment, insurance companies should extract has not reported outstanding claims reserve.
    Insurance companies should be based on factors such as insurance risk and empirical data, at least by the chain-ladder method, payment method, reserve development method, B-F in the two assessments had not reported an outstanding loss reserve, selection and assessment of maximum value to determine the best estimate.
    An insurance company shall report on the detailed report has not outstanding claims reserve based data, calculation methods and parameters, and the underlying data sources, data quality, and reserve the reliability of the result.
    Insurance company responsible for the actuarial data base cannot ensure the reliability of the results, or less than 3 years experience in related business data, the insurance company shall not be less than the actual compensation expenditures in the fiscal year 10% report on the extraction has not outstanding claims reserve.
    Article 38th of short term health insurance business, insurance companies should extract the unearned reserve.
    Short-term health insurance extraction not due responsibility reserves, should used following method one of: (a) one-twenty fourth hair premium method (to months for based meter mention); (ii) one-three hundred and sixty fifth hair premium method (to days for based meter mention); (three) according to risk distribution status can used other more caution, and reasonable of method, extraction of not due responsibility reserves shall not below method (a) and (ii) proceeds results of smaller who.
    39th short term health insurance not yet due liabilities the extracted amount shall not be less than the following, whichever is the greater of: (a) changes in the expected future payments and fees after deduction of the related investment income balance (ii) reserve evaluation date assuming that all surrender the surrender value of the policy.
    Shortage of unearned reserve, reserve for insufficient premiums shall be drawn to cover unearned reserves and larger the difference between the two in the preceding paragraph.
    40th long-term health insurance not yet due liabilities provision for measures shall be executed in accordance with the relevant provisions of the China insurance regulatory Commission.
    41st insurance company shall before and after reinsurance reporting to the CIRC, respectively to obtain results.
    Sixth chapter management 42nd insurance companies health insurance insurance reinsurance business, shall comply with the Insurance Act and the provisions relating to the regulation of reinsurance business.
    Article 43rd reinsurance subsidiaries and foreign insurance companies, insurance companies branches may handle health insurance re-insurance business.
    Seventh chapter legal liability article 44th of insurance company violates these measures under article eighth, by the China insurance regulatory Commission ordered insurance companies to correct within; it fails to, given a warning by the CIRC, fined 30,000 yuan fine.
    45th an insurance company violates these measures from 13th to 15th, 20th to 23rd on the provision of article, by the China insurance regulatory Commission ordered insurance companies to stop selling the product, and fined a maximum of 30,000 yuan for insurance companies, responsible for the actuarial, legal liability of those responsible be warned.
    46th an insurance company violates these measures article 24th, may endanger the solvency of insurance companies, CIRC shall be ordered to stop selling the product.
    47th provisions of an insurance company violates these measures relating to sales management, granted by the China insurance regulatory Commission warned, fined 30,000 yuan fines; directly responsible for senior managers and other persons directly responsible to warn, fined 5000 Yuan fine.
    48th actuarial liability for breach of the provisions relating to actuarial approach, by CIRC in accordance with relevant laws and administrative rules and regulations will be punished.
    49th an insurance company branch office in violation of the article 43rd provisions of reinsurance of health insurance, fined 30,000 Yuan by the China insurance regulatory Commission, and the senior management staff and other persons sentenced to fined a maximum of 5000 Yuan.
    The eighth chapter by-laws 50th before the implementation of these measures promulgated by the China insurance regulatory Commission provisions inconsistent with this approach, is subject to this approach. 51st before the implementation of these measures of insurance companies in the health insurance business, these measures are not fully equipped with the prescribed conditions, shall meet the conditions as provided herein within the period specified.
    Specific measures shall be prescribed separately by the China insurance regulatory Commission.
    52nd explain these measures by the China insurance regulatory Commission.
                                                53rd these measures shall come into force on September 1, 2006.

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