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    Title: 我國團體醫療保險理賠爭議之研究
    Other Titles: The study of claim controversy over group health insurance in Taiwan
    Authors: 周羿妡;Chou, Yi-hsin
    Contributors: 淡江大學保險學系保險經營碩士在職專班
    郝充仁;Hao, Chung-jen
    Keywords: 理賠因素;健康保險;團體健康保險;Claim factors;Health Insurance;Group Health Insurance
    Date: 2008
    Issue Date: 2010-01-11 02:01:57 (UTC+8)
    Abstract: 近年來隨著台灣社會的進步,國民對健康保險的需求與日俱增,民眾對於商業健康保險的需求,並沒有因全民健保的實施而減少,反而逐年增加,健康保險中尤其以團體健康保險更能以有限的費用提供企業員工最基本的保障。
    保險公司的理賠服務優劣,最受消費大眾的注意,為減少理賠的爭議,使客戶滿意,讓所有購買團體健康險的保戶得到應有的保障。本研究以團體醫療保險在理賠時常會面臨的問題為主軸,透過與保險業界具代表性之各中高階主管,用個案深入訪談與意見交換的方式,探討保險業者在面對這些常見的團體醫療保險理賠糾紛時所處理的方式,將所獲得的結果提出值得注意事項,以作為保險業者未來經營團體健康保險之參考,並做出結果如下:
    1. 一般保險公司在承保團體險時,主要是以團體的平均損率來做考量,而非以個別被保險人的條件來做衡量,只要理賠的經驗尚可,且被保險人在投保時事先告知,經過評量後,所收的保費扣除必要費用後的利潤可以承擔,大多會允諾承保。
    2. 團體險的核保會較一般個人險寛鬆,在逆選擇的防阻上,會特別注意,一般而言,非固定雇主及會員制的團體較不會承保,因被保險人的素質不齊,很難評估損率。
    3. 對於新團體的投保,會用價錢高或限縮理賠條件等方式來降低理賠風險,並利用經驗分紅的方式,利誘要保單位自我控制團體成員的性質。
    4. 團體險對於道德危險的控管,在於對異常的案件做出統計分析,看是否集中在某特定區域、某特定醫療院所、某可疑的特定醫療模式等,並做個案追蹤以減少不當理賠。
    5. 當被保險人發生多重病症,而其中某項病症涉及除外責任時,可就單一除外病症來做扣除。若難主張某病症是除外,或無法舉證多重病症中有某項疾病與除外疾病是有因果關係時,保險公司是無法主張除外責任。
    With the development of Taiwan society, the demand of health insurance by the nationals has increased in recent years. The demand of commercial insurance has not decreased due to the implement of National Health Insurance. In contrast, the demand of commercial insurance has been increased. Within all types of health insurances, group health insurance can provide the basic cover at limited price for employees in enterprises.
    What consumers concern the most is the quality of the claims services of insurances. This study attempted to assist the insurance industry to reduce the controversy of customer claims, and satisfy customer demands; meanwhile, to help the insurants who have purchased group health insurance to be able to obtain proper cover. This study took the frequent disputes of group health insurance while being claimed as the main stream and utilized the method of individual in depth interview and exchanged ideas with the high-level supervisors who are representatives of insurance industry to observe how insurers handle these disputes. We concluded some directions from the finding
    of the study for insurance industry to use as reference. These conclusions are as follow:
    1.When an insurance company underwrites group health insurance, the average loss rate is usually considered as the main measurement instead of the individual condition of the insurants. As long as the claim experiences are adequate, and that the insurants have notified the general condition in advance and the profit after calculation is acceptable, the insurance company usually would promise underwriting.
    2.The underwriting process of group health insurance is easier than general personal insurance, so the insurers would pay more attention on adverse selection. In general, the institutions which have no persistent employers or those operating in membership would not be underwritten because the quality of the insurants is diverse and the loss rate is hard to evaluate.
    3.Insurers would raise the price or limit the claim conditions to reduce the underwriting risks when new institutions insure. In addition, insurers would utilize experience dividend to tempt the insurant to control their participant’s quality.
    4.The moral risk management of group health insurance is the statistic analysis on abnormal events. The analysis can reveal whether the events centralize to certain region, medical institution or specific medical care mode. Thus, the insurers can trace the individual case to reduce improper claims.
    5.When the insurant has multiple diseases and one of the diseases is on the list of exceptions, this disease can be deducted from the benefit. If there is difficulty to prove a certain disease is exception or to prove the cause and effect relation between the multiple diseases and exceptive disease, the insurer can not declare the exception responsibility.
    Appears in Collections:[保險學系暨研究所] 學位論文

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