Interim Measures for the Management of Serious Illness Insurance issued

To implement the Guiding Opinions of the National Development and Reform Commission, the Ministry of Health, the Ministry of Finance, the Ministry of Human Resources and Social Affairs, the Ministry of Civil Affairs, and the Insurance Regulatory Commission on the Implementation of Guiding Opinions on Serious Diseases Insurance for Urban and Rural Residents (hereinafter referred to as the “Guiding Opinions”) to promote the healthy development of urban and rural residents’ illness insurance and protect the The lawful rights and interests of the masses have recently been issued by the China Insurance Regulatory Commission as the Interim Measures for the Administration of Major Insured Insurance Businesses for Urban and Rural Residents of Insurance Companies (hereinafter referred to as the “Measures”).

On the basis of the “Guidance Opinions”, the “Measures” clearly stipulates the conditions for market access and withdrawal of serious illness insurance. Insurance companies that require serious illness insurance must have sufficient solvency; there are no major violations of laws and regulations in the past three years; Strong health insurance actuarial technology; and need to be equipped with professionals with professional backgrounds such as medicine; with a complete and relatively independent health insurance information management system. If an insurance company violates relevant regulations during the bidding process, if it is subject to more than three administrative penalties in the course of carrying out major illness insurance business, or if it pays irregularities in handling fees or gives kickbacks or other benefits other than those stipulated in the insurance contract, the insurance regulatory agency will not list it within three years. Into the list of critical illness insurance qualifications.

The "Measures" strictly supervise the bidding behavior of insurance companies and require the bid documents to be approved by the insurance company's head office and issue actuarial opinions, legal opinions and corresponding power of attorney. It is forbidden for bidders to falsify and falsify each other, collude with each other in bidding quotations, engage in price competition in a malicious manner, pay bribes to members of the tenderee, members of the bid evaluation committee, or take other unfair competition measures, and divulge information provided by the tenderer to the insured personnel. The "Measures" also require the Insurance Regulatory Bureau to follow the bidding process and supervise the insurance companies to participate in serious disease insurance bids in compliance with the law.

The "Measures" regulates the insurance company's implementation of major illness insurance business and requires insurance companies to formulate special insurance products for critical illness insurance. Based on the basic medical insurance experience data provided by policyholders, an insurance actuarial model for major illnesses is established, scientifically formulated product parameters, and pricing rates are determined. Pricing. The insurance company is required to strengthen communication and cooperation with the relevant government departments to realize the connection between the major disease insurance information system and the basic medical insurance information system, the medical assistance information system and the medical institution information system, and strictly enforce the user rights management to ensure information security.

The "Measures" require insurance companies to strengthen capacity building for serious illness insurance services. Establish a professional team for serious illness insurance, provide consultation and inquiry services for the insured person through telephone and internet, set up service outlets according to the distribution of the insured, and provide convenient services for the insured and the insured. Strengthen the convergence of major illness insurance and basic medical insurance and medical assistance, and provide "one-stop" instant settlement services and off-site medical settlement services. Based on the relevant provisions of the Guiding Opinions, the Measures stipulates that insurance companies should, under the authorization of the competent medical insurance department, go through medical inspections, stay in hospitals, check medical records, etc., according to standards or regulations such as clinical treatment standards and clinical pathways. , Do a good job in the supervision and management of medical behaviors, timely notify the policyholders and relevant government departments of irregularities found in the name of medical treatment, bed-bed hospitalization, over-medical treatment and other violations, and put forward related treatment suggestions.

The “Measures” require insurance companies to independently account for major illness insurance, strengthen fund management, strictly verify business costs, and strictly cover expenditures for managing major illness insurance costs, strengthen cost control, reduce the cost of serious illness insurance management, and increase operating efficiency. The Measures particularly require insurance companies to follow the principle of balance of payments and low-cost principals, and to negotiate with policyholders to reasonably determine the rate of serious illness insurance claims and the rate of increase of fees and profits. Establish a dynamic risk adjustment mechanism, and adjust the insurance liability and premium rate in the next insurance period to adjust the risk of excess balances and policy losses, etc. during the insurance period based on actual business results, adjustments in medical insurance policies, and changes in medical expenses. Regulation to ensure the sustainable development of major illness insurance business.

The "Measures" require the insurance regulatory authorities to strengthen the market entry and withdrawal of serious illness insurance. At the same time, they must strengthen supervision of market behavior, ensure orderly competition, improve service quality and level, and explore and research the protection level and the satisfaction of the insured as the core. Insurance assessment system for critical illness insurance. The insurance company refuses to honor the insurance contract or pay insurance money in accordance with the law, violate the regulations, disclose the information of the insured, have commercial bribery or unfair competition in the process of bidding or contracting for serious illness insurance business, and compile or provide false business data. With regard to financial statements and other acts, the insurance regulatory authority will impose severe penalties on the basis of the Insurance Law and related regulations.