商業保險理賠適用全民健保給付標準之探討
A Study on the Application of National Health Insurance (NHI) Medical Service Benefit Items and Payment Standards in Commercial Insurance Claims
商業性人身保險之理賠給付，是否應採用與全民健康保險相同之標準為據；若商業保險契約約款有約定手術給付之保險金以全民健康保險醫療費用支付標準列舉之手術為限，此是否等同保險理賠項目亦限制必須符合「全民健保支付標準」，此為目前保險理賠實務之爭議問題。基此，商業性保險之理賠是否應受限於全民健康保險之支付標準，或容有討論空間。本文試就此議題從商業保險商品之設計與定價、保險契約之解釋原則與方法等角度為分析。
Both National Health Insurance (NHI) and commercial medical insurance function to cover the insured’s medical expenses. However, whether the claims settlement of commercial personal insurance should adopt the same standards as those under NHI remains a contested issue. Where the terms and conditions of a commercial insurance policy provide that surgical benefits are limited to surgeries listed in the NHI Fee Schedule and Reference List for Medical Services, does this also mean that the items eligible for insurance claims are likewise limited to those that comply with the standards? This issue currently constitutes a point of dispute in insurance claims practice. Accordingly, whether commercial insurance claims should be constrained by the NHI payment standards or whether room for alternative interpretation exists warrants further discussion. This article attempts to analyze this issue from the perspectives of the design and pricing of commercial insurance products, as well as the principles and methods of insurance contract interpretation.
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