Why is the medical expenses not fully covered by car insurance claims?

The insurance company's medical expenses that are not related to medical insurance expenses and traffic accidents will not be compensated.

1. Medical expenses related to traffic accidents will be reimbursed according to the national medical insurance. Medical insurance is divided into three categories: A, B, and C. Category B is the majority of reimbursement (the reimbursement ratio varies from place to place, such as 97% for Class B drugs in Zhejiang, 60% and 90% for Anhui Province), and Category C is self-paid expenses, which will not be compensated by the insurance company.

You say that 10% of a certain drug cannot be claimed, and it is considered as a Class B drug. Specifically, you can call ** to the local medical insurance center for consultation or the medical insurance office of the treating hospital, in fact, it is now directly indicated on most of the drug lists. Expenses unrelated to traffic accidents will not be reimbursed, such as the injured person's own pre-existing diseases, diabetes, high blood pressure**.

Some people upstairs said that the proportion of liability, 7,000 yuan of medical expenses do not need to consider the proportion of liability, all in the compulsory traffic insurance medical items of 10,000 yuan of compensation.

2. The escort bed fee belongs to category C and is a self-paid item. If you deduct your nursing expenses, it should be that you have paid for the accompanying expenses, and the insurance company will deduct the nursing expenses.

3. The salary list of the three months before the accident should be provided, and the tax certificate should be provided if it exceeds 2000, if there is none, it may be according to the industry standard, or according to the household registration, according to the per capita income of urban or rural areas. The number of days depends on what kind of diagnosis you have, according to the "Personal Injury Injury Injury Lost Days of Lost Work Days" to determine the number of days lost work, such as soft tissue contusion is only 15 days. Up to the number of days in the hospital can be added.

If you have the idea, you can go through legal procedures or judicial appraisals, but I don't feel that you need to do this. If it is all insurance companies that do what I said above, it is basically reasonable, and if it is too big, you will go through the legal process.

The insurance company's incomplete medical expenses are to reduce the cost of claims and ensure the profitability of the product.

There is a deductible for reimbursement of general commercial medical insurance.

Restrictions on reimbursement scope, reimbursement ratio, etc. Whether the insurance company pays the full amount of medical expenses is subject to the insurance liability agreed in the terms of the product.

The medical expenses are based on the medical expenses issued by the medical institutions, the hospitalization bridge fee and other payment vouchers, combined with the medical records.

and proof of diagnosis and other relevant evidence. If the obligor of compensation has objections to the necessity and reasonableness of **, it shall bear the corresponding burden of proof.

The amount of compensation for medical expenses shall be determined on the basis of the amount actually incurred before the conclusion of the debate in the court of first instance. The compensation rights holder may file a separate lawsuit for the necessary expenses for organ function recovery training, appropriate cosmetic surgery fees, and other follow-up expenses. However, if the expenses that are determined to be incurred on the basis of the medical certificate or appraisal conclusion, they may be compensated together with the medical expenses already incurred.

If the insurance company does not settle the claim in full, it must be the part that the insurance company believes that there is an exemption from liability, and you can first communicate and negotiate the reason with the insurance company, and if you think that the reason is unreasonable, you can express your objection to the insurance company, and ask a third-party appraisal agency to conduct an appraisal, and choose whether to appeal to an arbitration institution or the court according to the appraisal results.

First of all, customers should know that insurance does not mean that the insurance company will bear all the medical expenses, and the insurance company will compensate the customer within the scope of the claim. When compensating, the insurance company will also consider the customer's liability in the accident, and if the customer bears a certain amount of responsibility, the insurance company will definitely set a certain deductible.

The reimbursement scope of medical insurance refers to the basic medical needs of the insured and the management of basic medical insurance drugs, diagnosis and treatment, etc., and the basic medical insurance stipulates the reimbursement scope of the drug catalog, diagnosis and treatment items and medical service facilities (commonly known as the "three catalogs"). The medical expenses incurred by the insured in the designated hospital in accordance with the three major catalogs shall be paid by the medical insurance** in accordance with the regulations.

Test your anti-risk index, experts will interpret it for you for free!

Whether the insurance company's medical expenses are fully compensated is subject to the insurance liability agreed in the terms of the product, and the incomplete compensation of medical expenses for some products is only to reduce the cost of claims and ensure the profitability of the insured products. The reimbursement of general commercial medical insurance has restrictions on the deductible, reimbursement scope (inside and outside social insurance), and reimbursement ratio.

Legal basis: Article 16 of the Interpretation of the Supreme People's Court on Several Issues Concerning the Application of Law in the Trial of Cases of Compensation for Damages in Road Traffic Accidents: Where a motor vehicle that has been insured at the same time as compulsory third-party liability insurance (hereinafter referred to as "compulsory traffic insurance") and third-party liability commercial insurance (hereinafter referred to as "commercial third-party insurance") causes damage caused by a traffic accident, and the parties sue the infringer and the insurance company at the same time, the people's court shall determine the liability for compensation in accordance with the following rules:

1) The insurance company that underwrites the compulsory traffic insurance shall first compensate within the limit of liability;

2) The shortfall shall be compensated by the insurance company that underwrites the commercial third-party insurance in accordance with the insurance contract;

Where the infringed party or their close relatives request that the insurance company that underwrites the compulsory traffic insurance in Qingzheng give priority to compensation for mental damages, the people's court shall support it.

Reimbursement rules vary slightly from company to company, but not because insurance companies have indemnity limits. The limit of the insurance company's compensation. The two sides of the roll-on travel negotiation, accompanied by the owner of the car to the insurance company to calculate the amount of compensation, by the insurance company within the scope of the strong insurance to bear the responsibility of the traffic accident compensation, this situation must be the responsible party of the insurance company compensation, the whole insurance party is only to prevent traffic accidents all the insurance has been paid, if the other party out of that is not the responsibility of the other party.

The following elements shall be present for a traffic accident:

1. It must be caused by a vehicle. Vehicles include motor vehicles and non-motor vehicles.

If there is no vehicle, it cannot constitute a traffic accident, for example, if a person on a large stool and a pedestrian collide while moving, it will not constitute a traffic accident;

2. It happened on the road. Roads refer to highways, urban roads.

and places that allow social motor vehicles to pass despite being within the jurisdiction of the unit include squares, public parking lots and other places used for public traffic;

3. Occurs in motion. It refers to the event that occurs in the process of driving or parking, if the vehicle is in a complete stop state, the pedestrian takes the initiative to collide with the vehicle or the passenger gets on and off the car in the process of crowding, falling, and ** accidents, it is not a traffic accident;

4. Something happened. It means that there are collisions, crushes, scratches, and overturns.

One of the phenomena such as car crash, **, fire, etc.;

5. The cause of the situation is man-made. It means that the occurrence of the situation is due to the fault or unexpected behavior of the person involved in the accident (the perpetrator). If it is due to various natural disasters that people cannot resist.

caused by traffic accidents;

6. There must be the occurrence of damage consequences of the hall bend. Damage consequences only refer to direct damage consequences and are material losses, including personal and property losses;

7. The psychological state of the party is negligence or other unexpected factors. If the person's mental state is intentional, it is not a traffic accident.

Escaping after a crash is subject to the following penalties:

1. Civil liability.

Where a party escapes after a traffic accident occurs, the party who escaped bears full responsibility, but where there is evidence to prove that the other party is also at fault, responsibility may be reduced.

2. Administrative responsibility.

If a person escapes after a traffic accident, if a crime has not yet been constituted, 12 points will be deducted at a time, a fine of up to 2,000 yuan will be imposed, and a concurrent detention of up to 15 days may be given. If a crime is constituted and the person escapes, the driver's license shall be revoked.

3. Criminal liability.

Whoever violates traffic and transportation management regulations, thereby causing a major accident that causes serious injury or death, or causes major losses to public or private property, is to be sentenced to up to three years imprisonment or short-term detention; where the circumstances of transportation are caused, a sentence of between three and seven years imprisonment is to be given; Whoever causes death as a result of escape shall be sentenced to fixed-term imprisonment of not less than seven years.

Whether the insurance company pays the full amount of medical expenses depends on the relevant provisions of the insurance contract. The scope of claims and the amount of compensation for different insurance products are different, and the reasonable use of drugs in the general social insurance can be reimbursed, and some drugs outside the social insurance can also be reimbursed, which is subject to the terms of the insurance. Insurance claimsOnly if the insured has a relevant insured accident within the validity period of the insurance, and the relevant medical expenses incurred are within the scope of the insurance contract, the insurance company will pay according to the insurance contract.

General commercial insurance.

In addition to the reimbursement of accidental outpatient medical expenses, another part of the reimbursement is commonly found in the reimbursement of inpatient medical expenses. Inpatient medical expenses insurance is mainly to cover the compensation of miscellaneous expenses such as bed fees, drug expenses, ** fees, and some examination fees of the insured. Different insurance companies have different coverage for this part of the cost, some include the cost of the surgery, and some list the cost of the operation as a single calculation.

For this part of the cost compensation, the insurance company only reimburses the amount of the insured's actual expenses minus the reimbursement of the unit on a pro-rata basis, but not the whole amount.

Test your anti-risk index, experts will interpret it for you for free!

Legal analysis: Generally speaking, the insurance company's claim amount will be compensated in strict accordance with the terms of the insurance contract, and the purpose of incomplete compensation for medical expenses in some insurance is to ensure the profitability of the insurance product. The reimbursement of general commercial medical insurance has restrictions such as deductible remorse, reimbursement scope (inside and outside social insurance), reimbursement ratio, etc., so you need to carefully read the terms and conditions before applying for commercial medical insurance to understand the reimbursement method of the insurance product.

Legal basis: Article 31 of the "Social Insurance Law of the People's Republic of China" Social insurance agencies may, according to the needs of management services, sign service agreements with medical institutions and drug business units to standardize medical services. Medical institutions shall provide reasonable and necessary medical services to insured persons.