Critical illness insurance payment regulations, critical illness insurance payment standards

Many people think that it is easy to buy insurance, but it is difficult to make a claim, but this is actually a wrong statement. As long as the payment regulations of critical illness insurance are met, as long as the insured has the protection agreed in the insurance contract, he can get the claim payment. So what are the payout rules for critical illness insurance?

Here's what you'll find out.

1. Confirmed by the hospital.

The diagnosis certificate issued by the hospital after checking whether the patient has a critical illness is undoubtedly an important basis for critical illness insurance claims. Therefore, when we want to find an insurance company to make a claim, the first step is to come to the hospital for a diagnosis!

2. Report the case to the insurance company.

Of course, it is more important to report the case to the insurance company in a timely manner. Once we have a medical certificate from the hospital, the next step is to report the case to the insurance company. It should be noted that there is a time limit for reporting the case, and the insurance company will not pay the claim after the time limit.

3. Submit the application materials to the insurance company.

When we come to the insurance company to file a claim, we must not forget to submit the information required by the insurance company. For example, claim forms and insurance contracts, outpatient medical records, etc. The speed at which an insurance company settles a claim is largely related to the completeness of the information submitted.

Fourth, the insurance company file and review.

After receiving the policyholder's application for claim, the insurance company should act cautiously when reviewing the relevant certificates and materials provided by the policyholder, carefully determine whether it is a valid insurance policy, whether the insurance is still within the claim settlement period, and so on.

5. The insurance company fulfills its obligation to pay compensation.

After reviewing the information and proof provided by the policyholder, the insurance company will pay compensation to the policyholder on the basis of determining the claim liability, and will fulfill its own compensation obligations according to the relevant insurance contract signed with the policyholder.

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It seems that there are 32 types of major diseases with the largest number of types. The compensation standard is implemented in accordance with the terms of the insurance company's critical illness insurance contract. If you buy this product, there will definitely be a standard table of critical illnesses in the insurance contract.

It's basically on the back pages of the insurance contract.

In the past, the state did not have unified regulations on the coverage and claim standards of critical illness insurance, and each insurance company formulated its own insurance terms and explained the claim standards, which caused many disputes. To this end, the Insurance Association of China and the Chinese Medical Doctor Association, in combination with the development of critical illness insurance in China and the progress of modern medicine, and drawing on international experience, jointly formulated the definition of critical illness insurance on August 1, 2007, and uniformly stipulated the scope and standards of insurance companies' claims for 25 major diseases, so as to protect the rights and interests of consumers.

However, consumers should also know that critical illness insurance will only pay out when the disease reaches the specified level, such as carcinoma in situ in the early stage of cancer, many companies will not compensate, so carefully check the definition of disease in the insurance terms.

In addition, the amount of critical illness insurance claims is the amount insured by the customer, not the actual amount spent at the time of the visit, and the consumer can be compensated if they are insured by multiple insurance companies.

Critical illness is a payout type, and the diagnosis payment does not mean that it can be paid as soon as it is diagnosed. Like cancer, you can pay as soon as you are diagnosed; Some of the other diseases need to reach a certain state or perform some kind of surgery to pay for them.

The payout of critical illness insurance depends on the contract.

Some need to look at the conditions and conditions agreed in the contract.

Claims do not require hospitalization information, only pathology reports and medical certificates, etc.

For example, the diagnosis is a brain tumor. However, there are three conditions listed in the clause, as long as you have 1-2 of them, you can get a claim. For example, if you have more than two chemotherapy treatments, you can apply for compensation.

Claim details may vary from insurer to insurer.

Therefore, the policyholder can bring the insurance policy, the insured's ID card, bank card, pathology report, diagnosis certificate, etc. to the insurance company's counter to handle the claim application.

1.Article 17 of the Insurance Law of the People's Republic of China stipulates that if an insurance contract is concluded and the standard clauses provided by the insurer are adopted, the insurance policy provided by the insurer to the policyholder shall be accompanied by standard clauses, and the insurer shall explain the contents of the contract to the policyholder. For the clause exempting the insurer from liability in the insurance contract, the insurer shall, at the time of conclusion of the contract, make a reminder sufficient to attract the attention of the policyholder on the insurance policy, insurance policy or other insurance certificate, and make a clear explanation to the policyholder in written or oral form of the content of the clause; If there is no reminder or clear explanation, the clause shall not be effective.

2.Article 23 stipulates that after receiving a request for compensation or payment of insurance money from the insurer or beneficiary of the leased to the insurance company, the insurer shall make an assessment in a timely manner; If the situation is complicated, the approval shall be made within 30 days, unless otherwise agreed in the contract. The insurer shall notify the insured or beneficiary of the verification results; For those who are liable for insurance, the obligation to compensate or pay insurance money shall be fulfilled within 10 days after reaching an agreement with the insured or beneficiary to compensate or pay insurance money.

If the insurance contract stipulates the time limit for compensation or payment of insurance money, the insurer shall perform the obligation of compensation or payment of insurance money in accordance with the agreement. If the insurer fails to perform the obligations provided for in the preceding paragraph in a timely manner, it shall compensate the insured or the beneficiary for the losses suffered thereby, in addition to paying the insurance money.

1. What are the critical illnesses in insurance?

1.Every insurance company has critical illness insurance, and if the insurance company names the product as critical illness insurance, and the insurance period is mainly for adults (critical illness insurance over 18 years old), the scope of diseases covered by the product shall include malignant tumors, acute myocardial infarction, sequelae of stroke, coronary artery bypass grafting (or coronary artery bypass grafting), major organ transplantation or hematopoietic stem cell transplantation, and end-stage renal disease (or chronic renal failure uremia stage).

2.In addition to these six diseases, insurance companies can choose to use other diseases within the scope of this standard; At the same time, the above-mentioned diseases shall use the disease names and disease definitions of this specification. However, the meaning of "critical illness" varies from insurance company to insurance company.

As a major type of health insurance, critical illness insurance has become a preferred type of insurance for people when applying for insurance, but many consumers think that critical illness insurance is "life protection", and it is more difficult to settle claims. According to the Measures for the Administration of Health Insurance issued by the China Insurance Regulatory Commission, if the insured is diagnosed with a disease according to the prevailing medical diagnostic standards after the health insurance contract takes effect, the insurance company shall not refuse to pay the insurance benefits on the grounds that the diagnostic standards are inconsistent with the insurance contract. This provision fundamentally resolves the controversy over the definition of insurance diseases, protects the rights and interests of consumers, and standardizes the principles for dealing with major diseases.

At the same time, consumers also need to pay attention to the following three key points when making critical illness insurance claims. First, a hospital diagnosis is required. When the insured person feels that there are signs of a serious illness in his or her physical condition, he or she will generally go to the hospital designated by the insurance company for treatment. During the consultation, the hospital will diagnose the physical condition of the insured person and conclude whether the insured has a critical illness and what kind of critical illness it is.

The diagnosis of the hospital will have a diagnosis certificate, and the diagnosis certificate is an important basis for critical illness insurance claims. Second, report the case in a timely manner. After the insured is diagnosed with a critical illness, he or she needs to check the policy to see if it is a critical illness as stated in the policy.

In general, critical illness is basically included in the insurance taken out by the insured. Next, the insured should report to the insurance company in time, either before or after hospitalization. After receiving the report, the insurance company will initiate the claim process and settle the claim.

Third, prepare the claim information. Experts from Huize Insurance Network remind that the following materials are generally required for critical illness insurance claims: first, diagnosis certificates, outpatient medical records, discharge summaries, and inpatient summaries, and diagnosis certificates from multiple hospitals need to be provided at the same time for treatment in multiple hospitals; the second is the receipt of medical expenses, receipts of hospitalization expenses and a detailed list of hospitalization expenses; The third is pathology, laboratory tests, imaging, electrocardiogram and other examination reports, which need to be stamped with the valid signature of the medical institution.

Critical illness insurance can generally be paid out in the following ways:

1.Report the case within three days of hospitalization. After the insured has an insured accident, it is also necessary to notify the insurance company in time and report the case to the insurance company;

2.According to the requirements of the insurance company, prepare the information required to apply for a claim, generally need to prepare a disease diagnosis certificate, or a hospital diagnosis report, a disease identification report, etc., and the specific information required needs to be determined according to the disease suffered by the insured;

3.Submit the claim information to the insurance company for review, and if the review is passed, the insurance company will transfer the claim money to the bank account designated by the insured.

If it is a death claim, then it is generally necessary to prepare a cremation certificate, a certificate of household registration cancellation by the public security organ and a medical death certificate issued by the hospital (some insurance companies usually only need two of them in order to simplify the claim procedure), and the insurance company will transfer the claim money to the bank account designated by the death beneficiary after approval.