中(zhong)國證券網訊(記(ji)者(zhe) 黃蕾)中(zhong)國證券網記(ji)者(zhe)獨家獲悉(xi),為促進上海(hai)市(shi)醫(yi)保(bao)(bao)專屬商業(ye)健(jian)(jian)康保(bao)(bao)險(xian)業(ye)務健(jian)(jian)康發(fa)(fa)展,維(wei)護保(bao)(bao)險(xian)消費(fei)者(zhe)的合法權益,上海(hai)保(bao)(bao)監局日前(qian)研究制定(ding)了(le)《上海(hai)市(shi)醫(yi)保(bao)(bao)專屬商業(ye)健(jian)(jian)康保(bao)(bao)險(xian)業(ye)務管理試(shi)點辦(ban)法》(以下(xia)簡稱(cheng)《辦(ban)法》),并將《辦(ban)法》下(xia)發(fa)(fa)至在(zai)滬各人身險(xian)公司。
《辦(ban)法》中(zhong)所稱的醫(yi)保(bao)專屬(shu)商業(ye)健康保(bao)險是指(zhi),上海市職工基(ji)本醫(yi)療(liao)保(bao)險參保(bao)人員,按照自(zi)愿原(yuan)則,使用(yong)職工醫(yi)保(bao)個人賬戶歷年結余(yu)資金或現金,為本人購買經保(bao)監會審(shen)批或備案、上海市政府認可的商業(ye)健康保(bao)險專屬(shu)產(chan)品,自(zi)從(cong)2017年1月1日(ri)起開始試(shi)點。
《辦(ban)法》中所(suo)稱的保(bao)(bao)險(xian)公(gong)司是指,在上海具有商業健康(kang)保(bao)(bao)險(xian)業務(wu)經營資(zi)質的人身保(bao)(bao)險(xian)公(gong)司及其分(fen)支機構。
明確業務經營準入門檻
根據《辦(ban)法》要求,保(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司(si)(si)經(jing)營(ying)醫保(bao)(bao)專屬商業健(jian)(jian)(jian)康保(bao)(bao)險(xian)(xian)(xian)(xian)業務應(ying)當具備以下條(tiao)件:以報(bao)告時點評估,專業健(jian)(jian)(jian)康保(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司(si)(si)所屬總(zong)公(gong)司(si)(si)上(shang)一年(nian)(nian)度末和最(zui)近季度末的(de)償付能力(li)不(bu)低(di)于(yu)100%,其(qi)他保(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司(si)(si)所屬總(zong)公(gong)司(si)(si)上(shang)一年(nian)(nian)度末和最(zui)近季度末的(de)償付能力(li)不(bu)低(di)于(yu) 150%;依法合規經(jing)營(ying),近三年(nian)(nian)內無(wu)重大違法違規行為(wei);在上(shang)海(hai)經(jing)營(ying)健(jian)(jian)(jian)康保(bao)(bao)險(xian)(xian)(xian)(xian)業務連續五(wu)年(nian)(nian)以上(shang),具有(you)成熟的(de)健(jian)(jian)(jian)康保(bao)(bao)險(xian)(xian)(xian)(xian)經(jing)營(ying)管理經(jing)驗和技術(shu);具備功(gong)能完善(shan)的(de)健(jian)(jian)(jian)康保(bao)(bao)險(xian)(xian)(xian)(xian)信息(xi)管理系統,能與(yu)上(shang)海(hai)市人(ren)身險(xian)(xian)(xian)(xian)綜合信息(xi)平臺實現對接和數據傳輸,并(bing)(bing)確(que)保(bao)(bao)信息(xi)安全;具有(you)經(jing)保(bao)(bao)監會審批或(huo)(huo)備案,并(bing)(bing)經(jing)上(shang)海(hai)市政府認可的(de)商業健(jian)(jian)(jian)康保(bao)(bao)險(xian)(xian)(xian)(xian)專屬產品(pin);具備完善(shan)的(de)業務、財務管理規定(ding),配備適應(ying)業務需(xu)要的(de)服務隊伍(wu);上(shang)海(hai)市政府相關部門或(huo)(huo)上(shang)海(hai)保(bao)(bao)監局規定(ding)的(de)其(qi)他條(tiao)件。
《辦法》要求,擬開展(zhan)醫保專(zhuan)屬商(shang)業健康保險(xian)業務(wu)的(de)(de)保險(xian)公(gong)司應向上海保監局報送開展(zhan)醫保專(zhuan)屬商(shang)業健康保險(xian)業務(wu)的(de)(de)報告。報告應提(ti)供(gong)符合《辦法》第五條所(suo)列條件的(de)(de)證明(ming)材料(liao),內容(rong)應當(dang)真實(shi)、準確、完整。
此外(wai),擬開展醫(yi)保(bao)(bao)專屬商業健康保(bao)(bao)險(xian)業務的(de)保(bao)(bao)險(xian)公司應提前完(wan)成系統(tong)改(gai)造,并經中(zhong)(zhong)國(guo)保(bao)(bao)險(xian)信(xin)(xin)息技術(shu)管理有限責任公司上(shang)海(hai)分(fen)公司(以(yi)下(xia)簡稱“中(zhong)(zhong)國(guo)保(bao)(bao)信(xin)(xin)上(shang)海(hai)分(fen)公司”)驗收通過。上(shang)海(hai)保(bao)(bao)監局(ju)將通過官方(fang)網站向社會公布保(bao)(bao)險(xian)公司名單(dan)。
應遵循微利經營原則
在產品(pin)管(guan)理方面,《辦法》同時要求,醫(yi)保專屬商業健(jian)康保險產品(pin)應遵循保障為(wei)主(zhu)、合理定(ding)價、微利經(jing)營原(yuan)則。
保(bao)(bao)險(xian)(xian)(xian)公司應(ying)根據(ju)上海(hai)市保(bao)(bao)險(xian)(xian)(xian)同業公會(hui)制(zhi)定(ding)(ding)的示范條款開發產品,并(bing)經(jing)保(bao)(bao)監會(hui)審批或備案。保(bao)(bao)險(xian)(xian)(xian)公司應(ying)定(ding)(ding)期(qi)回顧(gu)醫(yi)保(bao)(bao)專屬商業健康(kang)保(bao)(bao)險(xian)(xian)(xian)業務的總(zong)體經(jing)營狀況,進(jin)行(xing)產品定(ding)(ding)價(jia)回溯和(he)調(diao)整。產品定(ding)(ding)價(jia)回溯和(he)調(diao)整應(ying)遵循可(ke)(ke)持續經(jing)營原則(ze)和(he)保(bao)(bao)障投保(bao)(bao)人利益原則(ze),并(bing)經(jing)上海(hai)市政(zheng)府相關部門(men)認可(ke)(ke)。
在業務管理方(fang)面,《辦(ban)(ban)法》要(yao)(yao)求,保(bao)(bao)(bao)(bao)(bao)(bao)(bao)險(xian)公(gong)司應采(cai)取有(you)效手段對投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)人(ren)(ren)(ren)身份進行(xing)驗證(zheng),確保(bao)(bao)(bao)(bao)(bao)(bao)(bao)投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)行(xing)為(wei)系醫(yi)(yi)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)個人(ren)(ren)(ren)賬(zhang)(zhang)戶(hu)持有(you)人(ren)(ren)(ren)本(ben)人(ren)(ren)(ren)的真實意愿(yuan)。投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)人(ren)(ren)(ren)使用醫(yi)(yi)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)個人(ren)(ren)(ren)賬(zhang)(zhang)戶(hu)結(jie)余資金購買(mai)醫(yi)(yi)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)專屬商(shang)業健康保(bao)(bao)(bao)(bao)(bao)(bao)(bao)險(xian)產品,并在保(bao)(bao)(bao)(bao)(bao)(bao)(bao)險(xian)期間(jian)內要(yao)(yao)求退(tui)(tui)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)的,退(tui)(tui)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)金必須退(tui)(tui)回投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)人(ren)(ren)(ren)本(ben)人(ren)(ren)(ren)的醫(yi)(yi)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)個人(ren)(ren)(ren)賬(zhang)(zhang)戶(hu)。經(jing)市醫(yi)(yi)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)經(jing)辦(ban)(ban)機(ji)構核實,如(ru)因(yin)醫(yi)(yi)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)個人(ren)(ren)(ren)賬(zhang)(zhang)戶(hu)注銷(xiao)等原因(yin)造成(cheng)無法退(tui)(tui)回至原賬(zhang)(zhang)戶(hu)的,保(bao)(bao)(bao)(bao)(bao)(bao)(bao)險(xian)公(gong)司可采(cai)取投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)人(ren)(ren)(ren)認可的其(qi)他方(fang)式(shi)向其(qi)支(zhi)付退(tui)(tui)保(bao)(bao)(bao)(bao)(bao)(bao)(bao)金。
此外(wai),保(bao)險(xian)公司不(bu)得提(ti)供(gong)醫保(bao)專屬商業(ye)健康保(bao)險(xian)產(chan)品的保(bao)單貸款服務(wu)。
不得強制同時購買其他商業險
《辦法》要(yao)求,保(bao)險(xian)公(gong)司(si)經(jing)營醫保(bao)專屬商業(ye)健(jian)康保(bao)險(xian)業(ye)務(wu)不(bu)(bu)(bu)得(de)誤導公(gong)眾,不(bu)(bu)(bu)得(de)縮小保(bao)障(zhang)范圍,不(bu)(bu)(bu)得(de)強制同時購(gou)買(mai)其他(ta)(ta)商業(ye)保(bao)險(xian)產品(pin),不(bu)(bu)(bu)得(de)變(bian)(bian)相違(wei)規開展價格競爭(zheng)破壞保(bao)險(xian)市場秩序。保(bao)險(xian)公(gong)司(si)經(jing)營醫保(bao)專屬商業(ye)健(jian)康保(bao)險(xian)業(ye)務(wu)不(bu)(bu)(bu)得(de)詆毀同業(ye),不(bu)(bu)(bu)得(de)強制或(huo)變(bian)(bian)相要(yao)求投保(bao)人或(huo)被保(bao)險(xian)人變(bian)(bian)換保(bao)險(xian)公(gong)司(si),也不(bu)(bu)(bu)得(de)從其他(ta)(ta)保(bao)險(xian)公(gong)司(si)惡意搶奪(duo)客戶(hu)。
同(tong)時,保險公司應(ying)當加強對(dui)醫保專屬商業(ye)健康保險業(ye)務(wu)銷售(shou)人(ren)(ren)員的(de)培訓與(yu)管理,提高其職業(ye)道德和業(ye)務(wu)素質,不得(de)引導(dao)或縱容(rong)銷售(shou)人(ren)(ren)員從事違背誠信(xin)原則(ze)的(de)活動。發生銷售(shou)人(ren)(ren)員違規的(de),應(ying)及時妥善處置并進(jin)行(xing)責(ze)任追究。
保(bao)險(xian)公司應不斷提(ti)升專業服(fu)(fu)務(wu)水平(ping),向被(bei)保(bao)險(xian)人(ren)提(ti)供保(bao)險(xian)增值服(fu)(fu)務(wu),鼓(gu)勵為被(bei)保(bao)險(xian)人(ren)建立健(jian)康檔(dang)案、提(ti)供健(jian)康評估(gu)和咨詢(xun)等服(fu)(fu)務(wu),幫助被(bei)保(bao)險(xian)人(ren)提(ti)高(gao)健(jian)康水平(ping),降低疾病發生率。保(bao)險(xian)公司應為投(tou)保(bao)人(ren)和被(bei)保(bao)險(xian)人(ren)提(ti)供便捷多樣的保(bao)單查詢(xun)服(fu)(fu)務(wu)與理(li)賠信息(xi)查詢(xun)服(fu)(fu)務(wu),其中應包(bao)括互聯網(wang)自(zi)助查詢(xun)渠道。
保(bao)險(xian)公司應(ying)做(zuo)好理賠(pei)服務,杜(du)絕拖賠(pei)、惜(xi)賠(pei)、無理拒賠(pei)等(deng)行為,并(bing)借助信息網(wang)絡或通(tong)過與醫(yi)療機構(gou)加(jia)強合作等(deng)方式(shi),優化理賠(pei)流程。保(bao)險(xian)公司應(ying)建(jian)立(li)醫(yi)保(bao)專屬商(shang)業健康保(bao)險(xian)理賠(pei)回訪(fang)制(zhi)度。保(bao)險(xian)公司應(ying)當建(jian)立(li)完善的醫(yi)保(bao)專屬商(shang)業健康保(bao)險(xian)業務投(tou)訴(su)處理機制(zhi),設立(li)統一(yi)的投(tou)訴(su)電(dian)話(hua),并(bing)建(jian)立(li)投(tou)訴(su)處理臺賬,詳(xiang)細記錄客(ke)戶投(tou)訴(su)內容(rong)及(ji)處理情況。
保(bao)(bao)險公司因業(ye)務管(guan)理不完(wan)善,導(dao)致投(tou)保(bao)(bao)人醫保(bao)(bao)個人賬戶資金(jin)產生損失的(de),應承擔(dan)相應的(de)責任。
保(bao)險(xian)(xian)公(gong)司(si)不再經營(ying)醫保(bao)專(zhuan)屬(shu)商業健康保(bao)險(xian)(xian)業務(wu)時(shi),應向上海保(bao)監局報(bao)告并按(an)照(zhao)合同約定(ding)做好原承保(bao)客戶(hu)的(de)續(xu)保(bao)和后續(xu)服務(wu)工作(zuo)。若(ruo)客戶(hu)選擇轉換保(bao)險(xian)(xian)公(gong)司(si),其他經營(ying)醫保(bao)專(zhuan)屬(shu)商業健康保(bao)險(xian)(xian)業務(wu)的(de)保(bao)險(xian)(xian)公(gong)司(si)應接受(shou)其投保(bao),并給予原合同約定(ding)的(de)續(xu)保(bao)待遇。
應在財務管理上單獨核算
在財(cai)務管理方面,保(bao)(bao)(bao)險(xian)(xian)公(gong)司應當對醫(yi)保(bao)(bao)(bao)專(zhuan)屬(shu)商業(ye)(ye)健(jian)康保(bao)(bao)(bao)險(xian)(xian)業(ye)(ye)務進(jin)行單獨核(he)算,單獨識(shi)別和匯(hui)總相關的(de)保(bao)(bao)(bao)費收入、賠付支出、費用(yong)支出等損益項目,準確反映醫(yi)保(bao)(bao)(bao)專(zhuan)屬(shu)商業(ye)(ye)健(jian)康保(bao)(bao)(bao)險(xian)(xian)業(ye)(ye)務的(de)經營(ying)結果,并(bing)單獨出具醫(yi)保(bao)(bao)(bao)專(zhuan)屬(shu)商業(ye)(ye)健(jian)康保(bao)(bao)(bao)險(xian)(xian)業(ye)(ye)務的(de)利潤(run)表、費用(yong)明細表及報告。
保(bao)(bao)險(xian)公司(si)(si)應制定(ding)醫(yi)保(bao)(bao)專(zhuan)屬商(shang)(shang)業健康(kang)保(bao)(bao)險(xian)業務(wu)(wu)費(fei)用管理辦法,合理確定(ding)各類(lei)費(fei)用歸屬對象,據實歸集(ji)和(he)分(fen)攤(tan),不得(de)擠占(zhan)其(qi)他(ta)業務(wu)(wu)的成本(ben),不得(de)把其(qi)他(ta)業務(wu)(wu)的成本(ben)分(fen)攤(tan)至該(gai)業務(wu)(wu)中。保(bao)(bao)險(xian)公司(si)(si)高(gao)管人(ren)員薪酬(chou)福利不得(de)納入醫(yi)保(bao)(bao)專(zhuan)屬商(shang)(shang)業健康(kang)保(bao)(bao)險(xian)業務(wu)(wu)經(jing)營管理費(fei)用。醫(yi)保(bao)(bao)專(zhuan)屬商(shang)(shang)業健康(kang)保(bao)(bao)險(xian)業務(wu)(wu)不得(de)產(chan)生業務(wu)(wu)招(zhao)待費(fei)和(he)禮品費(fei)用。
保(bao)險(xian)公司應據實列(lie)支(zhi)經營(ying)醫保(bao)專屬商業健康保(bao)險(xian)業務所發生的(de)各項費(fei)用(yong)(yong),不斷加(jia)強對費(fei)用(yong)(yong)的(de)控(kong)制力度(du),切實提高(gao)費(fei)用(yong)(yong)管理水(shui)平(ping),降低經營(ying)成(cheng)本。保(bao)險(xian)公司應建立(li)醫保(bao)專屬商業健康保(bao)險(xian)內部監督(du)檢(jian)查機制,每年應至少進行一次專項財(cai)務檢(jian)查。
在監(jian)督管(guan)理方面,上海醫保(bao)(bao)專屬商業(ye)健(jian)康保(bao)(bao)險業(ye)務(wu)(wu)經營情況(kuang)應當接受市政(zheng)府相關部門和社會公眾的(de)監(jian)督。上海保(bao)(bao)監(jian)局依法對醫保(bao)(bao)專屬商業(ye)健(jian)康保(bao)(bao)險業(ye)務(wu)(wu)實(shi)行(xing)業(ye)務(wu)(wu)監(jian)管(guan)。
經營(ying)醫保(bao)專屬商業(ye)健康(kang)保(bao)險業(ye)務的(de)保(bao)險公(gong)司,應(ying)嚴格執行(xing)保(bao)險監管法(fa)律法(fa)規(gui)及(ji)本試點(dian)辦法(fa)的(de)有關(guan)規(gui)定(ding)。對(dui)存在違(wei)法(fa)違(wei)規(gui)行(xing)為的(de),上海(hai)保(bao)監局(ju)將(jiang)予以嚴肅(su)查(cha)處。情(qing)節嚴重的(de),將(jiang)在公(gong)布(bu)名(ming)單中予以除名(ming)。
中(zhong)證(zheng)網(wang)聲(sheng)(sheng)明:凡本網(wang)注(zhu)明“來(lai)源(yuan):中(zhong)國證(zheng)券(quan)(quan)報(bao)·中(zhong)證(zheng)網(wang)”的(de)所有(you)作(zuo)品(pin),版權均屬(shu)于中(zhong)國證(zheng)券(quan)(quan)報(bao)、中(zhong)證(zheng)網(wang)。中(zhong)國證(zheng)券(quan)(quan)報(bao)·中(zhong)證(zheng)網(wang)與(yu)作(zuo)品(pin)作(zuo)者(zhe)聯合聲(sheng)(sheng)明,任何組織未經中(zhong)國證(zheng)券(quan)(quan)報(bao)、中(zhong)證(zheng)網(wang)以(yi)及作(zuo)者(zhe)書面(mian)授權不(bu)得轉(zhuan)載、摘(zhai)編(bian)或(huo)利(li)(li)用(yong)其(qi)(qi)它方式使用(yong)上(shang)述作(zuo)品(pin)。凡本網(wang)注(zhu)明來(lai)源(yuan)非中(zhong)國證(zheng)券(quan)(quan)報(bao)·中(zhong)證(zheng)網(wang)的(de)作(zuo)品(pin),均轉(zhuan)載自其(qi)(qi)它媒(mei)體,轉(zhuan)載目(mu)的(de)在于更好服(fu)務讀者(zhe)、傳遞(di)信息(xi)之(zhi)需,并不(bu)代表本網(wang)贊同其(qi)(qi)觀點,本網(wang)亦不(bu)對其(qi)(qi)真實性負責,持異(yi)議者(zhe)應(ying)與(yu)原出(chu)處單(dan)位主張權利(li)(li)。
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Copyright 2001-2018 China Securities Journal. All Rights Reserved