社会医疗保险与商业医疗保险衔接的法律协调研究

发布时间：2018-06-30 05:34

本文选题：社会医疗保险 + 商业医疗保险　；参考：《哈尔滨工业大学》2017年硕士论文

【摘要】：保险制度因其在抵御风险方面的作用,被称为社会安全网。社会保险与商业保险在不同领域担负这一任务,医疗领域的风险由社会医疗保险与商业医疗保险共同分担应对。医疗保险体系存在着诸如社会医疗保险保障力度较小无法有力的保障人们应对日益增长的医疗费用、社会医疗保险与商业医疗保险之间的竞合使得有限的医疗保险资源无法得到最佳配置等问题。这些问题的解决之道指向了社会医疗保险与商业医疗保险更好地衔接。实现二者的衔接有助于多层次医疗保险体系建设,提高公民应对医疗风险的能力,促进社会和谐稳定。首先对社会医疗保险与商业医疗保险的基础概念进行准确界定,归纳对比二者的特点,结合二者自身特点、客观功能发挥、政策支持、实践校验等因素证明互补性的存在,互补性的论证为二者衔接提供了理论支持,证明了衔接的可行性。通过剖析损失填补原则产生的原因、价值、功能明确其适用于医疗保险领域的正当性与必要性,指导医疗保险金的给付。其次,分析社会医疗保险与商业医疗保险的衔接现状,发现现有指导二者衔接的规范文件层级太低,《保险法》人身保险与财产保险二分导致损失填补原则无法在医疗保险领域贯彻适用。实践运行中社会保险保障力度小,社会医疗保险与商业医疗保险竞合纠纷的频发,也呼吁社会医疗保险与商业医疗保险更好的融合衔接,以充分发挥商业保险的补充作用,提高医疗保险保障水平。通过对域外国家改革实践模式的研究,发现域外国家积极扩大商业医疗保险在医疗保险体系中的作用,同时也注重推进保险领域法律法规的完善以提供制度保障,这些为中国衔接实践提供了启示。最后,法律层面相应问题的存在必然导致实践运行产生混乱,法律层面问题的解决为关键所在,也是难点所在。建议重述保险合同分类,依照保险金给付性质将保险合同区分为费用型补偿型保险与定额给付型保险,明确费用补偿型医疗保险适用损失填补原则;在《社会保险法》中对商业保险补充功能进行法律宣示,倡导民众自主购买;在修订后的《保险法》中增加保险公司建议义务,从费用补偿型医疗保险销售源头减少保险竞合纠纷。
[Abstract]:Insurance system is called social safety net because of its function in resisting risk. Social insurance and commercial insurance undertake this task in different fields. The risks in medical field are shared by social medical insurance and commercial medical insurance. There are health insurance systems, such as social health insurance, which is less effective in protecting people from rising medical costs. The competition between social medical insurance and commercial medical insurance makes the limited medical insurance resources unable to get the best allocation and so on. The solutions to these problems point to a better connection between social medical insurance and commercial medical insurance. Realizing the connection between them is helpful to the construction of multi-level medical insurance system, to the improvement of citizens' ability to deal with medical risks, and to the promotion of social harmony and stability. First of all, the basic concepts of social medical insurance and commercial medical insurance are accurately defined, the characteristics of the two are summarized and compared, and the existence of complementarity is proved by the combination of their own characteristics, the exertion of objective functions, policy support, practical verification and so on. The complementary argument provides theoretical support and proves the feasibility of cohesion. By analyzing the reason, value and function of the principle of compensation for loss, it is clear that it is proper and necessary to apply it to the field of medical insurance, and guide the payment of medical insurance gold. Secondly, it analyzes the current situation of social medical insurance and commercial medical insurance. It is found that the existing normative documents guiding the link of the two are too low, and the dichotomy of life insurance and property insurance in the "Insurance Law" results in the principle of loss filling being unable to be applied in the field of medical insurance. In practice, social insurance has a low degree of protection, and the frequent disputes between social medical insurance and commercial medical insurance are frequent. It also calls for a better convergence between social medical insurance and commercial medical insurance, so as to give full play to the complementary role of commercial insurance. We will raise the level of medical insurance coverage. Through the study of the practice mode of the reform of foreign countries, it is found that foreign countries actively expand the role of commercial medical insurance in the medical insurance system, and at the same time pay attention to promoting the perfection of laws and regulations in the field of insurance in order to provide system protection. These provide enlightenment for the practice of cohesion in China. Finally, the existence of the corresponding problems at the legal level will inevitably lead to confusion in the practice, and the solution of the legal problems is the key and the difficulty. It is suggested that the classification of insurance contract should be restated, and the insurance contract should be divided into two types according to the nature of payment of insurance gold, that is, expense compensation insurance and quota compensation insurance, and the principle of compensation for loss should be made clear in the medical insurance of expense compensation type. In the Social Insurance Law, the supplementary function of commercial insurance is declared by law, and the public is encouraged to buy it independently, and the insurance company's suggestion obligation is added to the revised Insurance Law. From the cost compensation medical insurance sales source to reduce insurance competition dispute.
【学位授予单位】：哈尔滨工业大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：D922.284;D922.182.3

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