What can t be reimbursed by commercial insurance?

Hello, I am the first person in the business of Pacific Shenzhen Branch, first of all, you have to see what the insurance you buy is covered? What is not insured, which is insured, it is impossible You buy a critical illness insurance, any problems will be insured for you, for example, if you buy critical illness insurance, only cover the critical illness specified in your contract, before applying for insurance, truthfully inform what are the problems with the body before, so that there is no problem,

Illegal acts, congenital diseases, pre-existing diseases, etc.

Exclusion of Liability. Article 6 The insurer shall not be liable to pay the insurance money if the insured is killed, disabled or burned due to the following reasons:

1) The intentional act of the policyholder;

2) The insured causes injury or suicide, except where the insured is incapacitated for civil conduct at the time of suicide;

3) Fighting, assault or assault caused by the insured's provocative or intentional acts;

4) Pregnancy, miscarriage, childbirth, illness, drug allergy, heat stroke, sudden death of the insured;

5) The insured undergoes cosmetic surgery and other internal and surgical procedures;

6) The insured fails to comply with the doctor's instructions and takes, applies or injects drugs without permission;

7) Nuclear **, nuclear radiation or nuclear contamination;

8) terrorist attacks;

9) The insured commits a crime or resists arrest;

10) The insured person is engaged in high-risk sports or participates in professional or semi-professional sports.

Article 7 The insurer shall not be liable to pay insurance money if the insured suffers injuries resulting in death, disability or burns during the following periods:

1) During war, military operations, insurrection or armed rebellion;

2) During the period during which the insured is intoxicated or under the influence of drugs or controlled drugs;

3) The period during which the insured is drunk driving, driving without a valid driver's license, or driving a motor vehicle without a valid driving license.

The above paragraph occurs.

6. In the event of the death of the insured, the insurer's insurance liability for the insured shall be terminated, and the unexpired net premium shall be refunded to the insured on a daily basis.

Hello, according to your question, as follows:

1. Can commercial insurance and medical insurance be reimbursed at the same time?

As the name suggests, commercial insurance is commercial insurance, that is, we can get corresponding protection from the insurance company by paying a certain premium to the insurance company.

If we are insured during the insurance period and the insurance contract is complied with, we will receive compensation from the insurance company.

There are many types of commercial insurance, which can be roughly divided into health insurance, accident insurance, life insurance and financial insurance.

Medical insurance is the abbreviation of social basic medical security, it is a social welfare security system launched by the state, which only provides protection for diseases, that is, if the insured is hospitalized due to illness during the insurance period**, then medical insurance can provide relevant reimbursement services.

If you want to know more about the role of medical insurance, click here:

The biggest difference between medical insurance and commercial insurance is that commercial insurance is for-profit insurance, while medical insurance is the welfare of the people, which is fully covered by the national finance, and the insurance threshold is relatively low, and the insured only needs to pay a small fee to obtain protection.

So can medical insurance and commercial insurance be reimbursed at the same time?

The answer is "yes", why do you say that? Because health insurance and business are different in nature in the first place, there is no essential conflict.

Secondly, commercial insurance is a supplement to social security, in which commercial medical insurance can reimburse medical expenses that are not reimbursed by medical insurance, which is equivalent to increasing the scope of reimbursement, and there is no conflict in principle.

That is, the medical expenses incurred by the insured's ** illness will be reimbursed by medical insurance first, and the remaining part of the expenses that meet the reimbursement standard of commercial medical insurance will be reimbursed by commercial medical insurance.

The rest of the commercial medical insurance, such as critical illness insurance, is not the same type of insurance as medical insurance, so there will be no conflict in the claim.

On the whole, there is no conflict between medical insurance and commercial insurance, and as long as the insured is in line with the contract, then the claim can be made at the same time.

Examination fees incurred during hospitalization are reimbursed, but outpatient expenses are not. Because commercial insurance coverage must be for expenses incurred during hospitalization. In the event of subsequent hospitalization, the pre-hospital outpatient clinic may be partially reimbursed.

The limit of examination fees for electroencephalogram, X-ray, radiograph, laboratory test, physiotherapy, acupuncture, CT, MRI and other examinations in the auxiliary examination center is 200 yuan; Surgery fee (refer to the national standard, more than 1,000 yuan will be reimbursed as 1,000 yuan). The elderly over the age of 60 are hospitalized in the Xingta Town Health Center, and the ** fee and nursing fee are compensated 10 yuan per day, with a limit of 200 yuan.

The general procedure for reimbursement is as follows: holding the medical insurance handbook and IC card - registering with the medical insurance office of the > hospital - > verification card - paying the hospitalization deposit - > hospitalization - the self-payment of the self-payment items must be agreed and signed by the patient - the self-payment part of the cash or IC card settlement standard and self-payment ratio > cash or IC card settlement - the hospital will advance within the scope of > overall planning - > settlement and discharge.

Legal analysis: medical insurance and commercial insurance can not be reimbursed at the same time, employee medical insurance and commercial insurance reimbursement is on a first-order basis, in the reimbursement should be reimbursed after the employee medical insurance, and then the commercial insurance insurance.

Legal basis: Social Insurance Law of the People's Republic of China

Article 2: The State shall establish social insurance systems such as basic endowment insurance, basic medical insurance, work-related injury insurance, unemployment insurance, and maternity insurance, to protect citizens' right to receive material assistance from the State and society in accordance with law in the event of old age, illness, work-related injury, unemployment, childbirth, and so forth.

Article 26 The treatment standards of basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with the provisions of the State.

Article 28 In line with the basic medical insurance drug list, diagnosis and treatment items, medical service facility standards and medical expenses, emergency and rescue medical expenses, in accordance with the provisions of the State from the basic medical insurance **.

Commercial insurance has different reimbursement situations according to different types of insurance:1If the insured is equipped with critical illness insurance, after being diagnosed with a critical illness, he or she must meet the conditions agreed in the contract, and will pay for the expenses used to make up for ** and the losses that need to be compensated.

2.If the insured person receives medical treatment and meets the medical requirements agreed in the contract, the insurance money will be paid to pay for medical expenses. 3.

After purchasing accident insurance, the insured can be compensated or compensated for the liability if the conditions for payment of insurance benefits are met due to death or disability caused by accidental injury, and the accident must be sudden, external, unintentional or non-diseased. 4.If you meet the requirements of death or total disability, you can get life insurance benefits to protect your family.

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

1. Commercial medical reimbursement insurance covers medical expenses! Medical expenses are clearly priced. For insurance with a clear price, the insurance law stipulates that the payout cannot exceed the list price! So the insurance company reports the rest of the social security report, legally!

2. No matter how you go to ** report first, the total amount cannot exceed your medical expenses! Commercial insurance will ask you if you have social security when you apply for it, because there is a difference in premiums with and without it! If you choose to have, you have to go to social security reimbursement first, even if it's just 10 yuan!

This is to prove that you are not cheating the insurance company and that you do have social security! When you give the original to the Social Security Administration, they will issue you a split slip indicating how much money you still have left unreimbursed! The role of this split order is equivalent to the original, take him to the insurance company for reimbursement, there is no problem!

And legally! 3. Most of the commercial insurance in the reimbursement category can only be reported for the remaining part of the social security! For example, social security will reimburse up to 20,000 outpatient expenses! But it is reimbursed proportionally, and when you spend 30,371 yuan, you can only report 20,000 yuan.

At this time, the remaining 10,371 yuan will be reimbursed by commercial insurance on a pro-rata basis. The part that exceeds 30371 is all borne by individuals!

Some insurance stipulates that it is outside the scope of social security, but there is a limit, such as 20,000 yuan! Of course, this payment will also be more!

Benefit-based commercial insurance (such as critical illness) has nothing to do with social security, as long as you get sick, you will give money, no matter whether you look at it or not, how much it costs! Only give the agreed amount!

4. You go to the insurance company first, and you can't prove that you have social security, and the insurance company will reimburse you in the way that you don't have social security (it will be much less), and then deduct the original and seal it as a voucher! This one is legitimate! If you want to go to social security again, the insurance company has to divide the order, and then it is social security that benefits, not you!

In short, social security is social welfare, while commercial insurance is for profit! One is willing to buy and the other is willing to sell! It's all up to you!

If you have any other insurance questions, please come: more insurance fish talk about insurance! ，

Summary. Hello, yes. There are two situations in which medical insurance cannot be reported, one is not within the scope of reimbursement, and the other is beyond the reimbursement ratio.

Many commercial insurance can be reimbursed, and the above medical insurance cannot be reported. When purchasing commercial medical insurance, it is necessary to make a good choice according to the actual situation, carefully study the detailed rules of commercial medical insurance, and purchase those that do not conflict with medical insurance reimbursement, so as to avoid disputes in the future.

Hello, yes. There are two situations in which medical insurance cannot be reported, one is that it is not covered by reimbursement, and the other is that the reimbursement ratio is exceeded. Many commercial insurance can be reimbursed, and the above medical insurance cannot be reported.

When purchasing commercial medical insurance, it is necessary to make a choice according to the actual situation, carefully study the detailed rules of commercial medical insurance and insurance loss, and purchase those that do not conflict with medical insurance reimbursement, so as to avoid disputes in the future.

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The scope and proportion of reimbursement that can be made by commercial insurance is determined according to the type of insurance. The scope and proportion of reimbursement are also different for different types of insurance. The reimbursement expenses of commercial medical insurance are outpatient expenses, medicine expenses, hospitalization expenses, nursing expenses, surgery expenses, etc.

OneWhat can be covered by commercial insurance?The scope of reimbursement that can be made by commercial insurance is determined according to the specific type of insurance. Commercial insurance includes medical insurance, accident insurance, critical illness insurance, car insurance, etc., and the claim coverage of different types of insurance is different. For example, commercial medical insurance usually covers doctors' outpatient expenses, drug expenses, hospitalization expenses, nursing expenses, surgery costs, various examination costs, etc., and there are cost compensation medical insurance and fixed payment medical insurance.

Accident insurance means that the insurance company will make a claim for the insured who suffers from an external, sudden, unintentional or non-disease accidental injury during the insurance period and causes death, disability, medical expenses or temporary loss of working ability. Car damage insurance pays for damage to the insured vehicle caused by an insured accident while the insured is driving the insured vehicle.

IIWhat is the reimbursement process for commercial insuranceThe reimbursement process for commercial insurance is:

1.Report the case in a timely manner. When the insured is in danger, he should report to the corresponding insurance company in time, and if the time for reporting the case exceeds the time specified by the insurance company, the insurance company is likely to refuse to settle the claim;

2.Claims acceptance. The insured needs to remind you in accordance with the regulations of the insurance company, prepare the materials required for the claim, and the insurance company will make a decision to accept the claim if it meets the acceptance requirements;

3.Claims review. The insurance company will arrange professional personnel to review the entire case according to the actual situation of the insured and the terms of the signed contract, and make a final decision on acceptance;

4.The compensation is received. If the insurance company decides to settle the claim, it will pay the insurance money to the insured within a few working days.

IIITypes of commercial insurance for traffic accidentsThe types of commercial insurance for traffic accidents are:

1.The full name of the third party insurance is the third party liability insurance.

Third-party liability insurance (referred to as three-liability insurance) refers to the economic responsibility that the insured or its permitted driver shall bear in accordance with the law if an accident occurs during the use of the insured vehicle, resulting in direct damage to the person or property of the third party, and the insurance company is responsible for compensation. At the same time, if the insured incurs arbitration or litigation costs with the written consent of the insurance company, the insurance company shall compensate the insured beyond the limit of liability, but the maximum shall not exceed 30% of the limit of liability.

2.Car damage insurance.

Vehicle damage insurance means that the insured or its permitted driver will compensate the insured vehicle within a reasonable range if an insured accident occurs while driving the insured vehicle, resulting in damage to the insured vehicle.