理賠為保險公司履行契約的承諾行動，目前商業保險中之健康保險給付雖僅占總保險給付金額的5%~11%，但依實務各公司的件數占比已達90%以上，在理賠管理上為主要的標的，本研究以理賠管理為重點，分析一套合理的理賠業務分工制度，與適當的理賠運作組織，並將理賠實務經驗、專業技能予以模組化，分析出自動化、專業化的理賠決策工具，可以使理賠管理更臻完整，而這些包含了流程管理、專家系統、道德危險偵測工具與管理性報表等作業處理電腦系統，有助於強化理賠作業效能；另外針對保險公司內部理賠實務經驗、專業技能與倫理道德之內控事項要求予以說明，以求降低理賠內部的風紀事件。 商業保險的醫療保險給付約占全民健康保險給付規模的17.78%，在資訊量上雖有很大的差距，但在審查制度上確有部份相同之處，本研究亦分析商業醫療保險之理賠控制及全民健康保險審查制度進行比較探討，及兩者目前互動模式，綜合歸納日後在適法性的考量下，尚可以合作的方案探討，期能降低保險詐欺、減少醫療資源浪費。 本文亦對理賠作業之運作，提出結論及對相關單位之建議方案，其中結論如下： (一)日後醫療險之新商品設計，應多從理賠實務觀點考量。 (二)理賠人員之培養，應著重實務經驗、專業技能與倫理道德。 (三)合理的理賠業務分工，與適當的理賠運作組織。 (四)制定一套嚴謹的SOP作業準則，協助理賠人員處理原則一致化。 (五)自動化的理賠作業處理電腦系統，以降低理賠人員的學習障礙。 (六)專業的理賠決策工具，包含專家處理系統與報表工具。 (七)與全民健保局的合作關係可再加強，來降低道德危險件之發生。 Claim is insurance company fulfills promise for customers. Presently, the health insurance payment that under the total of claim payment is about 5%-11%. However, according to the actual claims, the percentage of health insurance payment is up to 90%, which is the main concern of the claim management. This study puts claim management as the focus to analyze reasonable claim business distribution system and a proper claim operation organization. Also it will model the actual claim experiences and professional techniques and transmit the automatic and professional claim tools. It will make the claim management more completed. The computerized system which include process management, profession system, ethical risk detective tools and management reports, which will strengthen the efficiency of claim operation. In addition, in order to decrease the misconducts in the claim department itself, the explaination for internal accuse such as actual claims, professional techniques and claim ethics that happens within the insurance companies would be required. The health insurance, payment of the commercial insurance is about 17.78% compare whit National Health Insurance payment scale. Although the data is not very accurate, they are similar in the actual investigating system. In this study, it has comparison and discussion between the claim control of commercial health insurance and National Health Insurance screening systems and the reciprocal pattern between these two as well. It will finalize the cooperation of these two in the future under the appropriate lawful consideration in order to decrease the insurance fraud and waste of medical resource.
This study proposes the conclusion for claim operation. It also provides the suggestions for the related departments. The conclusions are as followings: 1)The actual claim besiness should be considered more for future health insurance products. 2)The training of the claim processing staffs should emphasize the hand-on experiences, professional skills and work ethics. 3)Setting up the reasonable claim business division and proper claim processing organization. 4)Setting up a conscientious for claim adjusted operation consistency SOP . 5)Having the automatic claim system to reduce the staffs'' learning difficulties. 6)Having the professional claim decision tools including the professional processing system and presentation tools. 7)Enhancing the cooperation with the Bureau of National Health Insurance to decrease the ethical risk.
