商業保險醫療必要性之再建構
Reconstructing Medical Necessity in Commercial Medical Insurance
新興醫療方式不斷發展，在健保有限資源下，醫療提供者藉自費項目創造利潤，「醫療必要性」爭議遽增。學說及實務發展出主、客觀等學說，然莫衷一是。本文自保險社會功能與醫病道德危險出發，指出主觀說於醫療商業化下已非妥適。另提出「修正客觀說」，以醫療常規為判斷標準，保險人如欲推翻診治醫師判斷，應負舉證責任。至於尚未形成常規之新興技術，則以附加保險另行精算費率，以兼顧保險對價平衡及維持社會經濟安定之制度功能。
With the continuous development of emerging medical treatments and the limited resources of the National Health Insurance system, healthcare providers have generated profits through self-pay medical services, resulting in a sharply growing number of disputes over “medical necessity.” Both academic scholarship and judicial practice have developed subjective, objective, and other approaches to determining medical necessity, yet no consensus has been reached. Drawing upon the social function of insurance and moral hazard on the part of both physicians and patients, this article argues that the subjective approach is no longer appropriate in the context of the commercialization of medical care. This article further proposes a “modified objective approach,” under which prevailing medical practice shall serve as the basis for determining medical necessity, and the insurer shall bear the burden of proof when seeking to rebut the treating physician’s medical judgment. As for emerging medical technologies that have not yet become established medical practice, this article proposes that they be separately incorporated into supplementary insurance with actuarially determined premiums, thereby balancing the equivalence between insurance premiums and coverage while preserving the institutional function of insurance in maintaining social and economic stability.
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