基本医疗保险解纷机制存在的问题与改革对策

The Problems in Dispute Resolution Mechanism of Basic Health Insurance and Reform Countermeasures

在基本医疗保险领域,劳动者、用人单位与社保经办机构基于用人单位行为形成的法律关系性质复杂,由此产生的纠纷也最为棘手。虽然现行法律、法规与司法解释使得社会保险纠纷的解纷机制"有法可依",但是"五险打包"的处理方式在劳动者维权途径与处理方法上存在问题,既没有区分基本医保作为事故赔偿型保险的特征,也没有认清当下的形势,且过度依赖社保行政机关。未来应当将基本医保领域的相关纠纷作为劳动关系纠纷来处理,即通过仲裁与民事诉讼的方式要求用人单位直接支付医保待遇,放弃目前的行政手段实现医保费用补缴的处理方法。

The legal relations among employer, employee and social insurance agency based on employer＇s behavior are very complicated and the disputes caused by them are also very diffi cult to deal with. Although current laws, regulations and judicial interpretations provide a legal basis to solve the disputes in social insurance system, the approach of ＂fi ve insurance package＂ caused a lot of problems and contradictions in employees＇ rights protection and processing methods. It neither differentiates the features of basic health insurance as accident compensation insurance, nor understands the present situation. It also excessively relies on the social insurance administrative departments. In the future, disputes in the field of basic health insurance should be handled as a labor relation disputes, that is, employees could require the employers to pay health insurance benefi ts directly by the ways of arbitration and civil proceedings. The current method of premium supplementary payment through administrative way should be given up.