Medical expenses refer to the expenses that the victim must pay for medical examination, treatment and rehabilitation training after suffering personal injury.Medical expenses include not only past medical expenses, such as treatment expenses and medical expenses, but also future medical expenses, such as rehabilitation expenses, plastic surgery expenses and othersFollow up treatment fee。
Chinese name
Medical expenses
Nature
Medical examination, treatment and rehabilitation training
Properties
Paid in the industrial injury insurance fund
Features
List of auxiliary equipment allocation organizations
Medical expenses refer to the treatment and rehabilitation treatment of employees who suffer from accident injuries or occupational diseases due to work, the treatment of injured employees who still need to be treated after the period of suspension with pay, and the treatment of injured employeesRecurrence of work-related injuryThe medical, surgical and other treatment costs incurred in the medical institutions that sign the service agreement (except in an emergency) for treatment after confirming the need, because these costs areIndustrial accidentThe direct consequence is alsoIndustrial injury insurance systemThe main purpose ofInjury on-the-JobMedical treatment, fromWork injury insurance Middle payment.
Compensation issues
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Calculation method
《Regulations on Work Injury Insurance》Paragraph 3 of article 29 states: "TreatmentInjury on-the-JobThe required fees are in accordance withemployment injury insuranceList of diagnosis and treatment items, list of drugs for industrial injury insuranceHospitalization service standard of industrial injury insuranceOf the. "Article 45 stipulates: "The handling institution shall sign a service agreement with medical institutions and auxiliary appliance allocation institutions on the basis of equal consultation, and publish the list of medical institutions and auxiliary appliance allocation institutions that have signed the service agreement. The specific measures shall be separately formulated by the labor and social security administrative department of the State Council in conjunction with the State CouncilHealth administrative department, formulated by the civil affairs department and other departments. "Article 46 stipulates: "The handling agency shall, in accordance with the agreement and relevant national catalogues and standards, check the use of medical expenses, rehabilitation expenses and auxiliary equipment expenses of the injured workers, and settle the expenses in full and on time."
According to this provision, the victim receivesIndustrial accidentThere is a prerequisite for medical compensation, that is, except for emergencies, employees receive medical treatmentInjury on-the-JobThey should seek medical treatment in the medical institution that signed the service agreement, and their fees should meetemployment injury insuranceList of diagnosis and treatment items, list of drugs for industrial injury insuranceHospitalization service standard of industrial injury insuranceAfter the above conditions are met, the victim can obtain compensation for medical expenses.
The calculation formula is:
Compensation amount of medical expenses=diagnosis and treatment amount+drug amount+inpatient service amount
Note: The calculation basis of the above diagnosis and treatment amount, drug amount and inpatient service amount is the directory of diagnosis and treatment items of industrial injury insurance, the directory of drugs of industrial injury insurance, and the inpatient service standard of industrial injury insurance.
For example, Wang, an employee of a construction company, had a fibula on his left leg due to the fall of the construction scaffold during constructionComminuted fractureHe was immediately sent to the Second Hospital of the city for medical treatment (the hospital signed a service agreement with the industrial injury insurance agency), and the diagnosis and treatment items he received were: blood pressure and ECG measurement 50 yuan, leg bandage fixation 200 yuan, X-ray fluoroscopy 160 yuan, and Baum radiation 350 yuan, of which the first three items were included in the industrial injury insurance diagnosis and treatment items, totaling 410 yuan, and the last item did not belong to thisProject scopeBut cannot be included;The drugs used are:Ulinastatin760 yuan, 450 yuan for non opioid analgesics,Schneider660 yuan, the first two belong toDrugs for industrial injury insuranceDrug use specified in the catalog, 1210 yuan in total;The inpatient service received by him is ordinary, 60 yuan/bed/day, 50 days in hospital, 3000 yuan in total, which is in line with the service standards for industrial injury inpatients.In this way, the compensation amount of Wang's medical expenses is:
Compensation for medical expenses=410 yuan+1210 yuan+3000 yuan=4620 yuan
It should be noted that《Regulations on Work Injury Insurance》The labor and social security administrative department of the State Council shall work together with the State Council to stipulate the above standardsHealth administrative department、Drug supervision and managementThe regulations of departments and other departments. In the case that specific regulations in this regard have not yet been issued, please refer to the regulations issued byMinistry of Labor and Social SecurityNational Development Planning CommissionState Economic and Trade CommissionThe Interim Measures for the Administration of the Scope of Medication of Basic Medical Insurance for Urban Employees jointly issued by the Ministry of Labor and Social Security, the National Development Planning Commission, the Ministry of Finance, the Ministry of HealthState Administration of Traditional Chinese MedicineThe standards determined in the Opinions on Determining the Scope of Basic Medical Insurance Service Facilities and Payment Standards for Urban Employees issued by the Ministry of Education of the People's Republic of China.
In the specific claim process of the victim, the provisions of the first paragraph of Article 19 of the Interpretation of the Supreme People's Court on Several Issues Concerning the Application of Law in the Trial of Personal Injury Compensation can be referred to.
Compensation principle
The principle of full compensation, that is, compensation should be made as much as the loss, and compensation should be consistent with the loss.It includes not only past medical expenses, but also future medical expenses.
Include content
1. Registration fee;
Note: Including hospital outpatient registration fee, expert outpatient registration fee, etc.
2. Medical expenses;
2.1 When determining the medical expenses, the principle of medication should adhere to the principle of "suit the medicine to the case", and the injury can be treated with ordinary drugs instead of expensive drugs.
2.2 The scope of drug use should be controlled within the scope of free medical care.
2.3 When determining the medical expenses, the prescription and the medical expense invoice should be reviewed organically (drugs that are not targeted, available, or used for other diseases are unreasonable drugs).
Note: It refers to the cost of purchasing drugs.
3. Inspection fee;
3.1 Attention shall be paid to excluding the expense of repeated inspection and high amount inspection (except for necessary injuries).
Medical expenses
3.2 After reasonable transfer, the examination conducted by the hospital on the basis of the original examination cannot be regarded as repeated examination.Note: Examination fee refers to the fee charged for determining the injury condition, including medical examination fees required for treatment, such as blood examination fees, fluoroscopy fees, CT fees, B-ultrasound fees, color ultrasound fees, etc.
4. Treatment cost;
Note: It refers to the expenses paid by the victim for receiving treatment, such as dressing change, injection, physiotherapy, surgery, chemotherapy, orthopedics, plastic surgery, etc.
5. Hospitalization expenses;
5.1 Hospitalization is only limited to serious injury or hospitalization to determine the injury condition and surgical treatment.
5.2 It should be strictly controlled whether the victims whose injuries can be cured in the outpatient department can be compensated for hospitalization expenses.
Note: Inpatient fee refers to the bed fee charged by the hospital for admission according to the hospitalization standardwater and electricityEtc.
1.1 About Implementation<General Principles of Civil Law of the People's Republic of China>Article 144 of the Opinions on Several Issues (Trial) stipulates that "in general, the diagnosis certificate of the local treatment hospital and the bills of medical expenses and hospitalization expenses shall be taken as the evidence".This establishes the principle of proximity treatment.
1.2 It is emphasized that the nearest hospital must be selected for treatment. Too strict treatment is not conducive to the protection of victims.Treatment nearby is a principle, but the actual situation and treatment needs should also be considered.In practice,Compensation obligeeIt may be a reasonable treatment if it is not treated in the nearest hospital.In this regard, reasonable treatment costs should also be compensated.
1.3 Of course, if it is neither the nearest hospital nor reasonable treatment, it will not be compensated.
2. About the transfer of hospital treatment.
2.1 Article 144 of the Opinions on Several Issues Concerning the Implementation of the General Principles of the Civil Law of the People's Republic of China (for trial implementation) stipulates that 1: "The expenses of going to another hospital for treatment without the approval of the medical department shall not be compensated generally."
2.3 In practice, for various reasons such as economic factors, the hospital where the victim went to see a doctor often refused to agree to the transfer of the victim for treatment when it did not have the corresponding diagnosis and treatment ability, resulting in the victim's delay in treatment, or unable to obtain compensation for medical expenses after the transfer.Therefore, the unreasonable restrictions on the transfer of victims in 2.1 have been eliminated in 2.2.
3. Treatment of induced diseases
aboutTortious conductThe treatment of the induced disease should generally determine the responsibility and proportion according to the considerable causal relationship (the size of the causal force).
4. Cost of follow-up treatment
Compensation obligeeAfter the end of the compensation proceedings, someFollow up treatment feeFor example, the necessary rehabilitation fees for organ function recovery training, appropriate plastic surgery fees, and other follow-up medical fees.
There are three specific operation methods:
4.1 Lump sum compensation, that is, the treatment costs that may occur in the future are all calculated and compensated in a lump sum (in this case, the inevitable costs must be determined according to the medical certificate or the appraisal conclusion before such treatment).
4.2 The future losses will be prosecuted separately, and the judicial interpretation of personal injury compensation stipulates that "the compensation obligee can sue separately after the actual occurrence".
4.3 Even if the one-time compensation is determined, if the expenses incurred by the actual treatment in the future exceed the amount determined by the one-time compensation, the compensation obligee has the right to sue for compensation for the excess.
For the determination of medical expenses, the method of allocation of burden of proof was adopted to solve the problem of judging the necessity and rationality of medical expenses (the originalForensic expertise).In principleCompensation obligee% of the victims bear the burden of proof on the existence and burden of medical expenses.Specifically, the victim should prove the existence and amount of medical expenses by providing medical expenses, hospitalization expenses and other vouchers issued by medical institutions, as well as medical records, diagnosis certificates and other evidence.IfIndemniteeIf the amount claimed and the evidence provided by the obligee for compensation are not recognized, or the obligor for compensation disagrees with the necessity and rationality of treatment, it shall bear the corresponding burden of proof.The court shall review the evidence provided by both parties in combination with the case, and judge whether the medical expenses are reasonable and whether the victim is properly transferred to another hospital through medical records, diagnostic certificates and other relevant evidence.
6. Insurance payment form of medical expenses
The form of insurance payment of medical expenses, referred to as medical insurance, is a kind of insurance to compensate for medical expenses caused by diseases.Social insurance where the society or enterprises provide necessary medical services or material assistance when employees are sick, injured or have children.As in ChinaPublic medical careLabor insurance and medical treatment.The medical expenses of Chinese employees shall be shared by the state, units and individuals to reduce the burden on enterprises and avoid waste.
Legal basis
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1. General Principles of Civil Law
Article 119 Anyone who infringes upon a citizen's body and causes injury shall compensate for medical expenses, reduced income due to missed work, living allowances for the disabled and other expenses;If it causes disability, it shall also pay funeral expenses, necessary living expenses of the deceased's dependents and other expenses.
Article 50 (1) Medical expenses: calculated according to the medical expenses incurred in the treatment of the patient's personal injury caused by the medical accident, paid according to the evidence, but excluding the medical expenses of the primary disease.If it is really necessary to continue treatment after the case is closed, it shall be paid according to the basic medical expenses.
When treating work-related injuries, employees shall seek medical treatment in the medical institution that has signed the service agreement. In case of emergency, they can first go to the nearest medical institution for first aid.
The expenses required for the treatment of work-related injuries meetemployment injury insuranceList of diagnosis and treatment items, list of drugs for industrial injury insuranceHospitalization service standard of industrial injury insurance, fromWork injury insurance Payment.The catalogue of diagnosis and treatment items of industrial injury insurance, the catalogue of drugs for industrial injury insurance, and the hospitalization service standards for industrial injury insurance shall be jointly established by the labor and social security administrative department of the State Council and the State CouncilHealth administrative department、Drug supervision and managementDepartment regulations.
If the cost of rehabilitation treatment for the injured worker to the medical institution that signed the service agreement meets the provisions of the third paragraph of this articleWork injury insurance Payment.
Article 31 Workers with work-related injuriesRecurrence of work-related injuryIf it is confirmed that it needs treatment, it shall enjoy the treatment for work-related injuries as stipulated in Articles 29, 30 and 31 of these Regulations.
4. Opinions of the Supreme People's Court on Several Issues Concerning the Implementation of the General Principles of the Civil Law of the People's Republic of China (for Trial Implementation)[1]
Article 144 The compensation for medical treatment expenses shall generally be based on the diagnosis certificate of the local treatment hospital and the transaction documents of medical expenses and hospitalization expenses.The expenses of going to another hospital for treatment without the approval of the medical department are generally not compensated;No compensation shall be made for the expenses incurred in the unauthorized purchase of drugs unrelated to the damage or treatment of other diseases.
According to Article 19 of the Interpretation of the Supreme People's Court on Several Issues Concerning the Application of Law in the Trial of Personal Injury Compensation Cases.The medical expenses shall be determined according to the medical expenses, hospitalization expenses and other collection vouchers issued by the medical institutions, combined with the medical records, diagnosis certificates and other relevant evidence.IndemniteeThose who disagree with the necessity of treatment shall bear the correspondingBurden of proof。
The amount of compensation for medical expenses shall be determined according to the amount actually incurred before the end of the court debate in the first instance.Rehabilitation costs necessary for organ function recovery training, appropriate plastic surgery costs and othersFollow up treatment feeThe right holder of compensation may file another lawsuit after the actual occurrence.However, the necessary expenses determined according to the medical certificate or the expert conclusion may be compensated together with the medical expenses already incurred.
2、 Interpretation of provisions
1. This article defines the compensation principle, compensation standard, calculation of compensation amount, rules of burden of proof, etc. of medical expenses.
2. The principle of compensation is that the compensation obligor compensates the victim for theUnlawful infringementFor the actual medical expenses, the people's court shall determine the amount of medical expenses in accordance with the receipts for medical expenses, hospitalization expenses, etc. issued by medical institutions and in combination with medical records, diagnostic certificates, and other relevant evidence.
3. In terms of the scope of compensation, it includes not only the medical expenses already paid by the victim, but also the rehabilitation costs necessary for organ function recovery training, appropriate plastic surgery costs and the possible futureFollow up treatment feeEtc.
4. Precautions in application:
(1) The "organ function recovery training fee" does not include the cost of psychological treatment after being violated illegally.
(2) As for "follow-up treatment fee", it refers to the fee required for the secondary treatment of the injury that the physical signs of the injury are fixed after treatment but the remaining dysfunction really needs to be treated again or the injury has not yet recovered.
If the victim is disabled due to injury, the necessary expenses incurred due to increased living needs and the income loss caused by the loss of labor capacity, includingDisability compensation、Cost of disability aids、DependentNecessary rehabilitation and nursing expenses actually incurred for living care and continuous treatmentFollow up treatment feeThe obligor of compensation shall also make compensation.
If the victim dies, the compensation obligor shall compensate for the relevant expenses specified in the first paragraph of this article in addition to the rescue and treatmentFuneral expenses、Living expenses of dependantsThe death penalty and other reasonable expenses such as transportation expenses, accommodation expenses and loss of work delay paid by the victim's relatives for funeral.
Article 19 The medical expenses shall be determined according to the medical expenses, hospitalization expenses and other collection vouchers issued by medical institutions, combined with medical records, diagnosis certificates and other relevant evidence.IndemniteeIf they disagree with the necessity and rationality of treatment, they should bear the correspondingBurden of proof。
The amount of compensation for medical expenses.It shall be determined according to the amount actually incurred before the end of the debate in the court of first instance.The necessary rehabilitation fees for organ function recovery training, appropriate plastic surgery fees, and medical certificates orexpert conclusionThe necessary expenses determined can be compensated together with the medical expenses already incurred.
Article 4 (1) Medical expenses refer to the expenses charged by the hospital for treating the injured party caused by electric shock.The medical expenses shall be determined according to the diagnosis certificate, prescription, medical expenses and hospitalization expenses of the treatment hospital.
