How to reimburse social security and commercial insurance at the same time? Is commercial insurance only reimbursed after social security reimbursement?

Give you a case to illustrate this problem intuitively. You should understand after reading it.

How to pay commercial insurance when there are both social security and commercial insurance?

A letter to the editor

Hello, experts!

In June 2009, I took out a life universal life insurance policy in a life insurance company, with the insured amount of10.5 million yuan and the annual premium of 6,000 yuan. I also bought two medical insurance (social insurance type) for hospitalization expenses, with a premium of 297.89 yuan.

In May, 2065438+00, he was admitted to the Provincial People's Hospital for 6 days because of "recurrent right epigastric pain". I was diagnosed as "calculous cholecystitis". * * * The total medical expenses incurred is 7952.02 yuan, including 25 19.33 yuan for operation, 5072.69 yuan for hospitalization and 360 yuan for outpatient service before and after hospitalization. Among the hospitalization expenses of 5072.69 yuan, the self-funded items are 323.54 yuan. The discharge statement shows that the medical insurance has paid 646.89 yuan for surgery and 6.04 yuan for hospitalization13/kloc-0, totaling 1962.93 yuan. On the day of discharge, I contacted my insurance agent Xiao Li to consult about insurance claims. Two days later, Xiao Li sent the claim documents: hospital operation fee payment 1685.2 yuan; The hospitalization expenses were 3089.8 yuan, and the outpatient expenses before and after hospitalization were 324 yuan, with a total amount of 5099 yuan.

What I want to ask is that the reimbursement rate of a life insurance product is 90%. I thought I could reimburse 7 156 yuan (7952.02× 90%), but I only reported 5099 yuan. Excuse me, financial experts, how is the payment amount of commercial insurance calculated? (Ms. Tian)

Hanhe expert review

Commercial medical insurance only reports the rest of social security.

Many people think that commercial insurance that social security cannot be reported should be reported, which is actually a misunderstanding. Commercial medical insurance implements the principle of compensation, and the insurance company will only reimburse the amount of social security reimbursement MINUS the self-funded part. In other words, the self-funded items of medical insurance, social security and commercial insurance will not be reimbursed.

Let's take a look at how the commercial medical insurance bought by Ms. Tian is reimbursed:

(1) social security payment

According to Ms. Tian's discharge statement, the medical insurance has paid 646.89 yuan for surgery and 6.04 yuan for hospitalization13/kloc-0. This 1962.93 yuan is the social security compensation part of Ms. Tian's hospitalization expenses.

(2) Commercial insurance payment

The commercial medical insurance purchased by Ms. Tian is the hospitalization expenses of a student. There are two types of social security in medical insurance. Social security refers to medical compensation based on social security compensation. The insurance benefits that Ms. Tian can enjoy are:

1. Insurance premium for hospitalization medical expenses: 90% of the actual medical expenses, with a maximum payment of 65,438+00,000.0 yuan each time;

B, before hospitalization 14 days (inclusive) to 30 days (inclusive) after discharge, outpatient medical expenses with the same reason as hospitalization shall be paid at 90%, with the maximum not exceeding 1000.0 yuan;

C hospitalization insurance: pay 90% of the actual operation cost, with a maximum payment of 5,000.0 yuan each time.

It can be seen that this kind of social security medical insurance is paid on the basis of social security payment, that is to say, when calculating the payment of commercial insurance, the payment part of social security medical insurance should be deducted first. In addition, the compensation ratio is 90%; Compensation items include: hospitalization expenses, hospitalization expenses and outpatient expenses; Ms. Tian's medical expenses totaled 7952.02 yuan, which did not exceed the compensation limit.

To sum up, Ms. Tian's claim calculation formula is:

Hospital operating expenses = (operating expenses 25 19.33- medical insurance has paid operating expenses 646.89) × 90% = 1685.2 yuan;

Hospitalization medical expenses = (total hospitalization expenses 7952.02- operation expenses 25 19.33- hospitalization medical expenses paid by medical insurance 13 16.04- medical insurance self-funded items 323.54) × 90% = 3089.8 yuan, with compensation of 3089.8 yuan;

Outpatient expenses before and after hospitalization = total expenses of outpatient receipts 360 × 90% = 324 yuan, with compensation of 324 yuan;

The total amount of commercial insurance compensation is 5099 yuan.

Including social security and commercial insurance, Ms. Tian paid hospitalization expenses of 706 1.93 yuan, with a total compensation ratio of 88.8%.

special

point out

As can be seen from the above analysis, Ms. Tian paid less than 30% of social security, and after paying commercial insurance, the payment ratio reached 88.8%.

It can be seen that commercial health insurance is an effective supplement to social security and can meet the different security needs of different groups of people.

Chengdu Business Daily reporter Liu Feng finishing