產險業經營健康保險之核保與理賠問題之研究

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Please use this identifier to cite or link to this item: https://tkuir.lib.tku.edu.tw/dspace/handle/987654321/32310

Title:	產險業經營健康保險之核保與理賠問題之研究
Other Titles:	A study on the issues of underwriting and claim for health insurance in the non-life insurance industry
Authors:	林國欽;Lin, Kuo-chin
Contributors:	淡江大學保險學系保險經營碩士在職專班林麗銖;Lin, Li-chu
Keywords:	健康險核保;健康險理賠;the Underwriting for Health Insurance;the Claim for Health Insurance
Date:	2007
Issue Date:	2010-01-11 01:58:09 (UTC+8)
Abstract:	本論文內容主要在分析產險業經營健康險所可能面對那些嚴酷的考驗與挑戰，尤其針對健康保險的核保與理賠兩項專業核心業務所可能面對的問題提出討論與建議，並期能達到下列預期效果：ㄧ、透過健康保險概述，瞭解健康保險之基本觀念、險種及各險種保障範圍、健康險相關條款與法律規定等。二、藉由健康保險市場現況之探討，以及我國目前壽險業經營健康險之經驗，探討經營健康險可能面對的問題。三、探討產險業經營健康險在核保上可能面對的挑戰，如：無法達成如壽險業一樣之良好核保效果、多元通路所形成的核保挑戰、法令遵循的不熟悉及體檢制度的難以建立的等問題。四、探討產險業經營健康險在理賠上可能面對的挑戰，如：醫療病歷資訊取得困難之問題、理賠詐欺案難以查覺、健康險理賠爭議申訴經驗不足及醫療病歷難以判讀等問題。五、最後，希望藉由上述問題之探討，提出建議方針或因應之道，作為產險業者未來經營健康險之參考。 This study aimed to analyze the trials and challenges the property insurance industry might need to cope with when providing health insurance services. Among others, issues about the two core activities of health insurance, underwriting and compensation, were proposed and discussed in an attempt to attain the following results: 1.An overview of the health insurance could help understand the fundamental concept of the health insurance, insurance types, coverage of each insurance type, and the rules and prescriptions pertaining to the health insurance. 2.The problems that health insurance providers might need to cope with were examined by probing into the current environment of the health insurance market and domestic life insurance industry’s experiences about managing the health insurance. 3.Challenges in the underwriting process that the property insurance industry might have to deal with included: an underwriting effect as good as that on the life insurance industry could not be attained, the underwriting challenge from multiple channels, unfamiliarity with prescriptions, and the difficulty in establishing a physical check-up system. 4.Challenges in compensation that the property insurance industry might need to deal with included: a poor access to medical records, the difficulty in detecting compensation fraud, lack of experiences in filing compliant for disputes in health insurance compensation, and the difficulty in analyzing medical records. 5.Finally, it was expected that suggestions or coping strategies could be worked out from the above-mentioned discussions and serve as a reference for property insurance providers to manage health insurance services in the future.
Appears in Collections:	[Graduate Institute & Department of Insurance Insurance] Thesis

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