What are the major illnesses covered by the critical illness medical insurance, and what diseases ar

Critical illness insurance covers specific critical illnesses such as malignancy, acute myocardial infarction, sequelae of stroke, major organ transplantation or hematopoietic stem cell transplantation, coronary artery bypass grafting, end-stage renal disease, multiple limb loss, acute or subacute severe hepatitis, benign brain tumor, chronic liver failure, sequelae of encephalitis or sequelae of meningitis, deep coma, deafness in both ears, blindness in both eyes, paralysis, heart valve surgery, severe Alzheimer's disease, etc.

[Legal basis].Article 28 of the Social Insurance Law.

Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facility standards, and emergency and rescue medical expenses shall be paid from the basic medical insurance in accordance with national regulations.

Article 29.

The part of the medical expenses of the insured persons that should be paid by the basic medical insurance** shall be directly settled by the social insurance agency and the medical institution and the drug business unit. The administrative department of social insurance and the administrative department of health shall establish a system for the settlement of medical expenses for medical treatment in other places to facilitate the insured persons to enjoy basic medical insurance benefits.

The above is only the current information combined with my understanding of the law, please refer to it carefully!

If you still have questions about this issue, it is recommended that you organize the relevant information and communicate with a professional in detail.

1. At present, there is no clear and unified definition of the "serious illness" category of "serious illness medical insurance" in China. According to the previous definition of critical illness insurance jointly formulated by the Insurance Association of China and the Chinese Medical Doctor Association, a total of 25 major illnesses have been clarified, including:

1) Malignant tumors – excluding some early-stage malignant tumors.

2) Acute myocardial infarction.

3) Stroke sequelae – permanent dysfunction.

4) Major organ transplantation or hematopoietic stem cell transplantation - allogeneic transplantation.

5) Coronary artery bypass grafting (or coronary artery bypass grafting) - thoracotomy is required.

6) End-stage renal disease (or chronic renal failure, uremia phase) – requires dialysis** or kidney transplantation.

7) Multiple limb loss – complete disconnection.

8) Acute or subacute severe hepatitis.

9) Benign brain tumors – craniotomy or radiation**.

10) Decompensated chronic liver failure – excluding alcohol or drug abuse.

11) Sequelae of encephalitis or sequelae of meningitis — permanent dysfunction.

12) Deep coma – not caused by alcohol or drug abuse.

13) Deafness in both ears – permanently irreversible.

14) Binocular blindness – permanent and irreversible.

15) Paralysis — permanently complete.

16) Heart valve surgery - thoracotomy is required.

17) Severe Alzheimer's disease – complete loss of the ability to live independently.

18) Severe brain injury — permanent functional impairment.

19) Severe Parkinson's disease – complete loss of the ability to live independently.

20) Severe burns—up to at least 20% of body surface area21) Severe primary pulmonary hypertension—with signs of heart failure.

22) Severe motor neuron disease – complete loss of the ability to live independently.

23) Loss of language ability – complete loss and positive for at least 12 months.

24) Severe aplastic anemia.

25) Aortic surgery - thoracotomy or laparotomy is required.

2. What is not covered by the medical insurance for serious illnesses?

1. Seeking medical treatment in a non-designated hospital without approval (except for emergency rescue);

2. Due to occupational diseases, work-related injuries or work-related injuries;

3. Injuries caused by traffic accidents;

4. Injury caused by one's own violation of national laws and regulations;

5. Food poisoning caused by liability accidents;

6. Caused by self-suicide (except for psychotic episodes);

7. Injury caused by medical accidents;

8. According to the regulations of the state and the city, the medical expenses shall be paid by themselves.

Critical illness insurance includes severe and critical illness insurance, including severe and life-threatening, unguaranteed quality of life, inability to take care of oneself, poor disease prognosis, and serious shortening of life.

At present, there are about 20 kinds of diseases included in the critical illness insurance in China, including malignant tumors such as leukemia, pheochromocytoma, small cell liver cancer, and acute myocardial infarction, which refers to irreversible infarction of the heart caused by myocardial ischemia.

Including: malignant tumors, acute myocardial infarction, sequelae of stroke, major organ transplantation or hematopoietic stem cell transplantation, coronary artery bypass grafting (or coronary artery bypass grafting), end-stage renal disease (or chronic renal failure uremia stage), multiple limb loss, benign brain tumor, chronic liver failure decompensation, encephalitis sequelae or meningitis sequelae, etc.

1. Malignant tumors.

Refers to the uncontrolled progressive growth and spread of malignant cells, infiltrating and destroying surrounding normal tissues, and can be menstrual blood. Diseases in which the tubes, lymphatic vessels, and body cavities spread to other parts of the body. The diagnosis is confirmed by pathological examination.

The clinical diagnosis falls under the category of malignancies under the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10).

2) Acute myocardial infarction.

Refers to partial myocardial necrosis caused by insufficient blood supply to the corresponding area due to coronary artery occlusion. At least three of the following conditions must be met:

1) Typical clinical manifestations, such as acute chest pain;

2) recent ECG changes suggestive of acute myocardial infarction;

3) diagnostically elevated cardiac enzymes or troponin, or dynamic changes consistent with acute myocardial infarction;

4) 90 days after the onset of the disease, the left ventricular function was confirmed to be reduced, such as the left ventricular ejection fraction was less than 50%.

3. Sequelae of stroke.

It refers to cerebral vascular hemorrhage, embolism or infarction caused by sudden lesions of cerebral blood vessels, and leads to permanent dysfunction of the nervous system. Permanent dysfunction of the nervous system, defined as one or more of the following disorders remaining 180 days after the diagnosis of the disease:

1) Complete loss of function of one or more limbs;

2) complete loss of language ability or ability to chew and swallow;

3) Complete loss of the ability to live independently, unable to perform three or more of the six basic activities of daily living independently.

4. Major organ transplantation or hematopoietic stem cell transplantation.

Major organ transplantation refers to an allogeneic transplant of the kidney, liver, heart or lungs due to organ failure.

5. Coronary artery bypass grafting (or coronary artery bypass grafting).

Refers to the most severe coronary heart disease, and the operation of coronary artery bypass grafting with thoracotomy was actually performed. Coronary artery stenting, cardiac catheterization balloon dilation, laser radiofrequency technology and other non-thoracotomy interventional procedures and laparoscopic surgeries are not covered.

Serious illness insurance is to reimburse urban and rural residents for the high medical expenses incurred due to serious illness, with the purpose of solving the problem of "poverty due to illness and return to poverty due to illness", so that the vast majority of people will no longer fall into economic difficulties due to illness.

On August 24, 2012, the National Development and Reform Commission, the Ministry of Health, the Ministry of Finance, the Ministry of Human Resources and Social Security, the Ministry of Civil Affairs, and the Insurance Regulatory Commission issued the Guiding Opinions on Carrying out Serious Illness Insurance for Urban and Rural Residents.

In view of the heavy burden of major illnesses on urban residents' medical insurance and the New Rural Cooperative Medical System, market mechanisms should be introduced to establish a serious illness insurance system to reduce the burden of serious illnesses on urban and rural residents, and the reimbursement ratio of serious illness medical insurance should not be less than 50%.

The Detailed Rules for the Implementation of the Social Insurance Law of the People's Republic of China jointly formulated the definition of critical illness insurance in accordance with the previous medical definition of critical illness insurance jointly formulated by the Insurance Association of China and the Chinese Medical Doctor Association, including: 1) malignant tumors - excluding some early-stage malignant tumors 2) acute myocardial infarction 3) sequelae of stroke - permanent functional impairment 4) major organ transplantation or hematopoietic stem cell transplantation - allogeneic transplantation 5) coronary artery bypass grafting (or coronary artery bypass grafting) - thoracotomy required.

There are different criteria for defining a serious illness. From an ethical point of view, it is a disease that is prone to life-threatening and death-threatening; From an economic point of view, it is a disease that is too expensive; From a medical point of view, it means that the grassroots cannot see the diseases that must be seen in large hospitals. We implement critical illness insurance, which is defined by cost.

The former Ministry of Health's NCMS major medical insurance started from the types of diseases, including 22 diseases such as childhood leukemia and congenital heart disease. However, this time it is explicitly required that the definition be based on the occurrence of high medical expenses. When the out-of-pocket portion of an individual's out-of-pocket payment exceeds a certain amount, it can lead to catastrophic medical expenses for the family, and this disease is a serious illness.

In the future, China will promote the smooth transition from NCMS critical illness insurance to critical illness insurance.

According to the World Health Organization's definition of "catastrophic medical expenditure" for a household, a household is considered to have incurred catastrophic medical expenditures if it is more than or more than 40% of the family's general consumption. Due to the different incomes in different places, the standards are also different. "The most important thing is to establish a stop-loss mechanism for residents to cope with catastrophic medical expenses, so as to improve the guarantee function of the medical security system.

This will be a better reflection of fairness. ”

[Legal basis].Detailed Rules for the Implementation of the Social Insurance Law of the People's Republic of China