- 學位論文
我國全民健康保險爭議審議制度之研究
Research of our country all the people health insurance dispute consideration system
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摘要
為謀社會福利，並增進民族健康，實現憲法對於人民生存權之保障，我國於民國84年3月1日正式施行全民健康保險制度。全民健康保險係屬強制性之社會保險，其目的係基於自助、互助的原則，及危險分擔、公共利益之考量，集合全國國民及政府的經濟能力，對全國國民提供基本的醫療服務。因此，凡符合加保資格之保險對象，均有依法以適當身分持續投保及繳納保險費之義務，且不得中斷。如此重大的變革，影響被保險人、投保單位及醫療院所之權利與義務甚鉅，故爭議事項必不可免。 全民健保開辦以來，中央健康保險局是唯一的保險人，有關保險對象之資格、投保金額、保險費、滯納金、罰鍰、保險給付、保險醫事服務機構特約管理等全民健保事件，均由中央健康保險局做出核定。為解決可能發生大量之醫療費用爭議案件，考量該爭議案件性質涉及高度醫學專業，恐為一般訴願機關所無法適任，且避免保險人被質疑球員兼裁判，乃於全民健康保險法第5條賦設審議全民健保爭議案件之專責機關為全民健康保險爭議審議委員會。人民或特約醫療院所對中央健康保險局所為處分不服，必須先向該會提出爭議審議之申請，才能向行政院衛生署及行政法院提起訴願及行政訴訟。因此，常為輿論所垢病，認為有疊床架屋之嫌。 本文即以上述問題為研究核心，首先釐清全民健保之法律關係，繼之概述各種法律關係下目前的行政救濟途逕。進而，以外國為鏡、案例為輔，提出健保爭審制度改革方案，期能兼顧人民權利之實現，又能有效減少上級機關負荷，增進行政效能。
並列摘要
In order to seek the social welfare, and promotes the national health, realized the constitution safeguard of regarding the people's right to subsistence, our country applies all the people health insurance system officially in March 1, 1995. All the people health insurance is the compulsory social security, its goal is based on the self-service, the cooperation principle, and the danger shares, consideration of the public interest, gathers the national and government's economic capacity, provides the basic medical service to the national. Therefore, every conforms to the additional insurance qualifications the insured object, has takes out insurance continually legally by the suitable identity and duty of the payment insurance premium, and do not interrupt. The so significant transformation, affects right and the duty insured of, the insurance unit and the healing institute is really great, therefore the dispute item must not be possible to exempt. Since all the people health insurance launch, the central health insurance bureau has been the only insurer, qualifications, the sum insured, the insurance premium, the fine for delayed payment, the fine, the insurance the related insured object pay, all the people health insurance events and so on insurance practice of medicine Service organization special management, makes the checking by the central health insurance bureau. Possibly has the massive medical expense dispute case for the solution, considers this dispute case nature to involve highly the medicine specialty, fears is unable the eligibility for the general petition institution, and avoids the insurer questioning that the player concurrently referee, is supposes in all the people healthy law of insurance 5th tax considers sole responsibility of institution all the people health insurance dispute case for all the people health insurance dispute consideration committee. The people or the special healing institute refuse to accept to the central health insurance bureau for the punishment, must to this meeting propose first application of the dispute consideration, can mentions the petition and the administrative proceedings to the Executive Yuan Department of health and the administrative court. Therefore, Chang Wei public opinion filthy sickness, thought that has suspicion of the unnecessary duplication. This article namely take the above question as the research core, first defines clearly of legal relationship all the people health insurance, outlines under each kind of legal relationship following it the present administrative relief way jing. Then, take foreign country as mirror, case for auxiliary, proposed that the health insurance struggle examines the system reform plan, the time can give dual attention to realization of the people's right, can also reduce the Higher organ load effectively, promotes the administrative potency.
參考文獻
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