產險業經營健康保險之核保與理賠問題之研究

A Study on the Issues of Underwriting and Claim for Health Insurance in the Non-Life Insurance Industry

林國欽(Kuo-Chin Lin)

指導教授 ： 林麗銖

淡江大學/商學院/保險學系保險經營碩士在職專班/碩士(2007年)

https://doi.org/10.6846/TKU.2007.00732

摘要

本論文內容主要在分析產險業經營健康險所可能面對那些嚴酷的考驗與挑戰，尤其針對健康保險的核保與理賠兩項專業核心業務所可能面對的問題提出討論與建議，並期能達到下列預期效果：ㄧ、透過健康保險概述，瞭解健康保險之基本觀念、險種及各險種保障範圍、健康險相關條款與法律規定等。二、藉由健康保險市場現況之探討，以及我國目前壽險業經營健康險之經驗，探討經營健康險可能面對的問題。三、探討產險業經營健康險在核保上可能面對的挑戰，如：無法達成如壽險業一樣之良好核保效果、多元通路所形成的核保挑戰、法令遵循的不熟悉及體檢制度的難以建立的等問題。四、探討產險業經營健康險在理賠上可能面對的挑戰，如：醫療病歷資訊取得困難之問題、理賠詐欺案難以查覺、健康險理賠爭議申訴經驗不足及醫療病歷難以判讀等問題。五、最後，希望藉由上述問題之探討，提出建議方針或因應之道，作為產險業者未來經營健康險之參考。

關鍵字

健康險核保 ； 健康險理賠

並列摘要

This study aimed to analyze the trials and challenges the property insurance industry might need to cope with when providing health insurance services. Among others, issues about the two core activities of health insurance, underwriting and compensation, were proposed and discussed in an attempt to attain the following results:
1.An overview of the health insurance could help understand the fundamental concept of the health insurance, insurance types, coverage of each insurance type, and the rules and prescriptions pertaining to the health insurance.
2.The problems that health insurance providers might need to cope with were examined by probing into the current environment of the health insurance market and domestic life insurance industry’s experiences about managing the health insurance.
3.Challenges in the underwriting process that the property insurance industry might have to deal with included: an underwriting effect as good as that on the life insurance industry could not be attained, the underwriting challenge from multiple channels, unfamiliarity with prescriptions, and the difficulty in establishing a physical check-up system.
4.Challenges in compensation that the property insurance industry might need to deal with included: a poor access to medical records, the difficulty in detecting compensation fraud, lack of experiences in filing compliant for disputes in health insurance compensation, and the difficulty in analyzing medical records.
5.Finally, it was expected that suggestions or coping strategies could be worked out from the above-mentioned discussions and serve as a reference for property insurance providers to manage health insurance services in the future.

並列關鍵字

the Underwriting for Health Insurance ； the Claim for Health Insurance

參考文獻

5、黃俊豪(2005)「醫療保險詐欺之研究」，淡江大學碩士論文

9、保德信國際人壽股份有限公司 http://www.prulife.com.tw

5、財團法人台灣醫療改革基金會 http://www.thrf.org.tw

7、周愫嫻、張耀中，「各國保險詐欺犯罪管制政策之比較研究」，刑事政策與犯罪研究論文集(9)，95年11月

參考資料來源