A Study on the Determination of “the Necessity of Hospital Stays” and the Claim-related Disputes of Commercial Health Insurance

• Main Authors: Kai-Wei Huang, 黃凱瑋
• Other Authors: Hilary Cheng
• Format: Others
• Language: zh-TW
• Online Access: http://ndltd.ncl.edu.tw/handle/8qbe28

碩士 === 元智大學 === 管理碩士在職專班 === 102 === Because of the growth of national income, the popularization of higher education and the development of internet information technology, consumers not only have a higher demand for insurance services, but also have increased knowledge of the insurance products and policies (regardless of the accuracy of such information). To protect their own rights, therefore, the consumers would appeal to different channels for problem solving once they feel unsatisfied with the results of handling their claims by the insurance firms. The number of claims-related disputes in the insurance industry, therefore, has been constantly increasing. By collecting and reviewing the relevant academic literature and business practices, this research endeavors to define and understand the relevant issues. An in-depth study has been made on a number of claims-related cases caused by disputes in determining the “Necessity of Hospital Stay”. The following conclusions have been reached after a process of inductive reasoning and analysis:- 1.In terms of the “Necessity of Hospital Stay”, a hospital stay shall only be considered necessary on the condition that it would normally be so recommended by physicians of the same professional background and under the same situation, so as to fulfill the spirit that all insurance contracts should be contracts of the utmost good faith (or Contracts Uberrimae Fidei). 2.The objectives of commercial health insurance are different from those of national health insurance (NHI). The NHI system is considered a pure social insurance system. The NHI policies, therefore, as not reckoned as medical regulations or guidelines. Whether the patient has accessed to the inpatient service as an NHI participant, therefore, should not be considered the sole criteria for determining the “Necessity of Hospital Stay”. 3.A clear, correct, and complete medical history should be established by the medical service institutions. An integrated medical history is a basic yet important part of the service provided by medical professionals to patients. It also provides significant facts for the insurance firms to understand the inpatient services received by the policyholder during the period and to determine the necessity for the hospital stay. Finally, the research also provides recommendations to the competent authority, the insurance firms and the consumers, with a hope that the information would be helpful for determining the “Necessity of Hospital Stay” and handling disputes in future.