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Medical insurance benefits refer to employers and employees paying medical insurance premiums in accordance with a certain rate and fee base to form a medical insurance fund, and the fund will provide certain compensation for the economic losses caused by the insured employees paying medical expenses due to illness.

Medical insurance benefits

Medical insurance benefits refer to employers and employees paying medical insurance premiums in accordance with a certain rate and fee base to form a medical insurance fund, and the fund will provide certain compensation for the economic losses caused by the insured employees paying medical expenses due to illness.

The acts of defrauding medical insurance treatment mainly include: the employee lends his medical insurance certificate to another person for treatment or alters various documents to falsely claim and overreport medical insurance premiums; the medical insurance management agency and its staff fraudulently obtain medical insurance for employees Fee for convenience. [1]

Chinese name

According to the provisions of China's current legislation, medical insurance benefits have the following main contents: ^[1]

The payment of medical insurance benefits means that after the employees participating in the basic medical insurance of the employees become ill, the medical insurance agency shall provide medical services to the sick employees for reimbursement of medical expenses in accordance with the conditions and treatment standards specified in advance. The payment of medical insurance benefits includes the benefits of the medical leave period and the payment of medical expenses. The benefits of the medical leave period will be explained in detail in section 3. This section will focus on the payment of medical expenses. ^[3]

According to Article 30 of the Social Insurance Law ^[4] , a total of four types of medical expenses are not included in the scope of payment of the basic medical insurance fund.

The first is medical expenses that should be paid from the work injury insurance fund. If an employee is injured due to work or suffers from an occupational disease, and it is identified as a work-related injury, the work-related injury insurance fund shall pay the relevant medical expenses. Medical expenses incurred by employees due to their own physical mechanisms or non-work-related injuries can generally be covered by the medical insurance fund.

The second is medical expenses that should be paid from the maternity insurance fund. If a female employee has paid maternity insurance, the medical expenses incurred due to pregnancy, childbirth, etc. that are not caused by her own physical mechanism should be reimbursed by the maternity insurance fund.

The third is medical expenses that should be borne by third parties. The treatment and medical expenses incurred by a third party infringement resulting in personal injury to the insured person shall be borne by the infringer and compensate the insured for economic losses. In addition, Article 30, paragraph 2 of the Social Insurance Law also stipulates that medical expenses shall be borne by a third party in accordance with the law. If the third party fails to pay or cannot determine the third party, the basic medical insurance fund shall pay first. After the basic medical insurance fund has paid in advance, it has the right to claim compensation from a third party.

Fourth, medical expenses incurred during your stay abroad. Medical expenses for the treatment of illnesses during overseas stays are generally covered by outbound personnel who purchase commercial overseas insurance on their own, and are not covered by the domestic basic medical insurance. ^[2]