基于理赔诉讼案例的健康保险惜赔识别研究

Underpayment Detection of Health Insurance Based on Claim and Lawsuit Cases

保险理赔难已引起社会的高度关注。对2000-2012年162个健康保险理赔诉讼样本进行实证分析,发现惜赔99例,惜赔率61.1%,其中拒赔72例,拒赔占惜赔的72.7%。保险惜赔深受索赔人谈判能力、保险金额、理赔人员素质的影响。保险公司对投保人拒赔金额甚于被保险人,对职工减赔金额弱于农民。无论拒赔金额还是减赔金额,均与保险金额正相关。保险公司对重大疾病拒赔金额甚于一般疾病,对住院超过15日的减赔金额甚于住院少于15日的金额。区县支公司拒赔金额甚于地市分公司,中西部地区拒赔金额和减赔金额均甚于东部地区。

h is difficult for insurance underpayment to attract enough attention from the society. This article makes an empirical analysis of 162 health insurance cases of claiming litigation during 2000 to 2012, and the authors find out that there are 99 underpayment cases and the underpayment rate is 61.1%. There are 72 denied cases and the cases take 72.7% of the underpayment cases. Underpayment is affected by the negotiation ability, insurance amount, and personnel professionalism of the claimant. The denial amount of insurance company to the applicant is more than that of the insured, and the reduction amount to workers is less than that of the farmers. Both denial amount and reduction amount are positively correlated to insurance amount. The denial amount to critical disease is more than that of the general disease, and the reduction amount to patient who stays in hospital more than 15 days is more than those less than 15 days. County level denial amount is more than city level branches. Both the denial amount and reduction amount in central and western areas are more than that in eastern China.