[[alternative]]The study of claim controversy over group health insurance in Taiwan

碩士[[abstract]]近年來隨著台灣社會的進步，國民對健康保險的需求與日俱增，民眾對於商業健康保險的需求，並沒有因全民健保的實施而減少，反而逐年增加，健康保險中尤其以團體健康保險更能以有限的費用提供企業員工最基本的保障。 保險公司的理賠服務優劣，最受消費大眾的注意，為減少理賠的爭議，使客戶滿意，讓所有購買團體健康險的保戶得到應有的保障。本研究以團體醫療保險在理賠時常會面臨的問題為主軸，透過與保險業界具代表性之各中高階主管，用個案深入訪談與意見交換的方式，探討保險業者在面對這些常見的團體醫療保險理賠糾紛時所處理的方式，將所獲得的結果提出值得注意事項，以作為保險業者未來經營團體健康保險之參考，並做出結果如下： 1. 一般保險公司在承保團體險時，主要是以團體的平均損率來做考量，而非以個別被保險人的條件來做衡量，只要理賠的經驗尚可，且被保險人在投保時事先告知，經過評量後，所收的保費扣除必要費用後的利潤可以承擔，大多會允諾承保。 2. 團體險的核保會較一般個人險寛鬆，在逆選擇的防阻上，會特別注意，一般而言，非固定雇主及會員制的團體較不會承保，因被保險人的素質不齊，很難評估損率。 3. 對於新團體的投保，會用價錢高或限縮理賠條件等方式來降低理賠風險，並利用經驗分紅的方式，利誘要保單位自我控制團體成員的性質。 4. 團體險對於道德危險的控管，在於對異常的案件做出統計分析，看是否集中在某特定區域、某特定醫療院所、某可疑的特定醫療模式等，並做個案追蹤以減少不當理賠。 5. 當被保險人發生多重病症，而其中某項病症涉及除外責任時，可就單一除外病症來做扣除。若難主張某病症是除外，或無法舉證多重病症中有某項疾病與除外疾病是有因果關係時，保險公司是無法主張除外責任。[[abstract]]With the development of Taiwan society, the demand of health insurance by the nationals has increased in recent years. The demand of commercial insurance has not decreased due to the implement of National Health Insurance. In contrast, the demand of commercial insurance has been increased. Within all types of health insurances, group health insurance can provide the basic cover at limited price for employees in enterprises. What consumers concern the most is the quality of the claims services of insurances. This study attempted to assist the insurance industry to reduce the controversy of customer claims, and satisfy customer demands; meanwhile, to help the insurants who have purchased group health insurance to be able to obtain proper cover. This study took the frequent disputes of group health insurance while being claimed as the main stream and utilized the method of individual in depth interview and exchanged ideas with the high-level supervisors who are representatives of insurance industry to observe how insurers handle these disputes. We concluded some directions from the finding of the study for insurance industry to use as reference. These conclusions are as follow: 1.When an insurance company underwrites group health insurance, the average loss rate is usually considered as the main measurement instead of the individual condition of the insurants. As long as the claim experiences are adequate, and that the insurants have notified the general condition in advance and the profit after calculation is acceptable, the insurance company usually would promise underwriting. 2.The underwriting process of group health insurance is easier than general personal insurance, so the insurers would pay more attention on adverse selection. In general, the institutions which have no persistent employers or those operating in membership would not be underwritten because the quality of the insurants is diverse and the loss rate is hard to evaluate. 3.Insurers would raise the price or limit the claim conditions to reduce the underwriting risks when new institutions insure. In addition, insurers would utilize experience dividend to tempt the insurant to control their participant’s quality. 4.The moral risk management of group health insurance is the statistic analysis on abnormal events. The analysis can reveal whether the events centralize to certain region, medical institution or specific medical care mode. Thus, the insurers can trace the individual case to reduce improper claims. 5.When the insurant has multiple diseases and one of the diseases is on the list of exceptions, this disease can be deducted from the benefit. If there is difficulty to prove a certain disease is exception or to prove the cause and effect relation between the multiple diseases and exceptive disease, the insurer can not declare the exception responsibility.[[tableofcontents]]目 錄 第一章 緒論 1 第一節 研究動機與目的 1 第二節 研究對象及限制 3 第三節 研究流程 4 第二章 文獻回顧 5 第一節 文獻探討 5 第二節 團體醫療發展與現況 9 第三節 商業性健康保險的分類 18 第三章 團體醫療險之探討 28 第一節 醫療費用上昇的原因 28 第二節 團體醫療費用的理賠流程探討 31 第三節 壽險公司團體醫療費用的控制 36 第四章 研究方法 40 第一節 研究方法選擇 40 第二節 研究設計與資料蒐集 42 第三節 研究方式與限制 44 第五章 專家訪談-目前團體醫療險理賠常見的問題 45 第一節 訪談對象與訪談大網 45 第二節 訪談內容的重點整理 48 第三節 訪談的結論 62 第六章 結論與建議 68 第一節 結論 68 第二節 建議 70 參考文獻 73 附錄 75 表 目 錄 表1-1- 1個人保費收入與團體保費收入占總健康保費收入表 1 表1-2- 1壽險業健康險保費收入結構 3 表2-2- 1台灣壽險業歷年團體醫療保險新契約件數與保額 13 表2-2- 2台灣壽險業歷年團體醫療保險有契約件數與保額 13 表2-2- 3台灣壽險業歷年團體醫療保險保費收入 14 表2-2- 4台灣壽險業歷年團體醫療保險給付與金額 14 圖 目 錄 圖1-3-1本文研究流程圖……………..……………….5 圖2-2- 1民國94年的人身保險各險別保費收入概況 12 圖2-3- 1健康保險的分類 18[[note]]學號: 794500362, 學年度: 9