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Tianjin Basic Medical Insurance Accidental Insurance Interim Provisions
 

Chapter 1  General Principles
    The first article  In order t欧洲杯开户平台o ensure that the basic medical insurance insurer occurs after accidental damage, he will be rescued, Reduce the risk of family and social acc欧洲杯开户平台idents, Promote family and social stability and harmony, According to the Municipal People's Government《 Several opinions on improving the city's basi欧洲杯开户平台c medical insurance system》( Jin Zhengfa〔2010〕52 No.), Formulate this regulation。
    Two  This regulation is applicable to insured persons who are appli欧洲杯开户平台cable to the urban employees and urban and rural residents' basic medical insurance( The following abbreviation: Insured person)。
    The accidental dama欧洲杯开户平台ge referred to this regulation refers to the insured person's sudden、 Foreign、 Non-my wishes of accidents cause damage、 Disability or death。 The insur欧洲杯开户平台ed person is due to floods、 Earthquake and other huge natural disasters caused by damage。
    Article 3  Establishing and Implementation of accidental da欧洲杯开户平台mage damage additional insurance( The following abbreviation: accidental damage insurance) System, Follow the following basic principles:
    ( 1) Persist 欧洲杯开户平台in rights and obligations。 Payment standards are compatible with fundraising level, Focus on ensuring accidental injury medical payment and accidenta欧洲杯开户平台l disability、 Death Payment。
    ( 2) persistence“ Time to pay for it、 ​​Revenue and expenditure balancing”。 Entrusted management of accidental damage ins欧洲杯开户平台urance funds、 Business operation, separate accounting、 Independent accounting。
    ( 3) Adhere to the connection with the basic medical insurance system。 欧洲杯开户平台Accidental damage insurance is raised in funds、 Insurance payment、 Management and other aspects with urban employees and urban and rural residents' ba欧洲杯开户平台sic medical insurance system。 Medical expenses that belong to the scope of accident insurance payment, No longer included in the payment scope of basi欧洲杯开户平台c medical insurance funds。
    Article 4  The accident insurance system is the government-led、 Supplementary medical insurance system entrusted to operat欧洲杯开户平台e insurance companies, It establishes、 Operation and supervision shall be implemented in accordance with these regulations。

    Chapter 2  Management and Sutra
    Article 5  Municipal Human 欧洲杯开户平台Resources and Social Security Administrative Department( The following abbreviation: Municipal Human Social Security Department) Supervisor accident i欧洲杯开户平台nsurance work; The financial department of the municipal financial department is responsible for improving the financial system and supervision and ma欧洲杯开户平台nagement of accidental damage insurance funds; Municipal Social Insurance Fund Management Center( The following abbreviation: City Social Security Cen欧洲杯开户平台ter) Responsible for the allocation of accidental damage insurance funds, And the implementation of business guidance and supervision of the entrusted 欧洲杯开户平台insurance company。
    Article 6  Establishing Tianjin Basic Medical Insurance Accidental injury additional insurance service center( The following abbr欧洲杯开户平台eviation: City Service Center), Unification of accidental injury insurance。
    Municipal Service Center accepts the business guidance of the Municipal S欧洲杯开户平台ocial Security Center, Responsible for applying for materials review and information entry work。 City Service Center set up a telephone consulting ser欧洲杯开户平台vice department, Report and business consultation at any time。
    Article 7  Task Insurance Company is on the street、 Township set up a service outlet, 欧洲杯开户平台Establish a comprehensive service outlet in the district and county social security branches。 Street and township service outlets accept accidental in欧洲杯开户平台jury declarations and be responsible for the office, Comprehensive service outlets while accepting the accidental injury application business, Accept 欧洲杯开户平台the district and county streets、 An accidental injury case reported by the township service outlets, President of the President。
    Article 8  Comprehen欧洲杯开户平台sive service outlets will be the street、 An accidental injury case transferred by the township service outlets is reported to the market service cente欧洲杯开户平台r in time。 City Service Center reviews the entry in accordance with the prescribed procedures。

    Chapter 3  Insurance range and insurance payment
    Article 9  欧洲杯开户平台An accidental damage occurs in the insured, Trusted Insurance Company should pay in accordance with the standards and objects determined in accordanc欧洲杯开户平台e with these regulations:
    ( 1) ​​Personal injury, Pay to the insured;
    ( 2) Those who are disabled for accidents, Pay to the insured;
    ( 3) Those who ar欧洲杯开户平台e accidentally dead, Pay to the legal beneficiary of the insured。
    Article 10  The insured person has one of the following situations that are not in 欧洲杯开户平台the list of insurance liability:
    ( 1) There are concealment、 Fraudic behavior;
    ( 2) Self-injury、 Self-harm、 Suicide;
    ( 3) The subjective beneficiary 欧洲杯开户平台subjectively intentionally caused the insurer to die、 Disability;
    ( 4) Driving after wine、 Driving without a license、 Driving with an invalid driving 欧洲杯开户平台license、 Motor transportation without a valid driving license driving causes damage;
    ( 5) Drunk、 Drug abuse, or because of baternions、 Drugs、 The infl欧洲杯开户平台uence of controlled drugs caused by accidental damage;
    ( 6) Due to abortion、 Childbirth、 Food poisoning、 Medical accident、 Accepting or self-diagnosis 欧洲杯开户平台and treatment causes accidents, and non-caused abortion caused by accidental injuries;
    ( 7) Due to the violation of laws and security management laws and regulations, accidental damage;
    ( eight) Co欧洲杯开户平台mpensation liability shall be borne by the third person;
    ( Nine) Compensation liability shall be borne by the Work Injury Insurance Fund;
    ( Ten) The m欧洲杯开户平台edical expenses of accidental harm to occurred abroad。

    Chapter 4  Fund raising and allocation
    Article 11  Insurance premiums of accidental damag欧洲杯开户平台e insurance are raised from urban employee large medical expenses rescue funds and urban and rural residents' basic medical insurance funds, The insur欧洲杯开户平台ed person does not pay the fee。
    Article 12  Accidental injury insurance funding standards shall be proposed by the municipal human and social securit欧洲杯开户平台y department in conjunction with the financial department, Determined after being approved by the Municipal People's Government。 The operation of the 欧洲杯开户平台system of economic and social development and accident insurance insurance, Report the Municipal People's Government for approval。
    Article 13  Paymen欧洲杯开户平台t plan for accidental damage insurance funds, From the municipal human and social security department in accordance with urban employees and urban and 欧洲杯开户平台rural residents' basic medical insurance, the actual number of insureds will be issued quarterly。 The Municipal Social Security Center will timely allocate funds 欧洲杯开户平台to the entrustment insurance company in accordance with the fund allocation plan。

    Chapter 5  declaration and claims
    Article 14  After acciden欧洲杯开户平台ts, The insured and related personnel are here5 Dial the service call or go to the service outlets on the spot during the day, Report accident time、 Location、 Reasons, 欧洲杯开户平台etc.。 The insured person died accidentally, Its legal beneficiaries need to be48 Report the case within hours。 For on-site exploration, Trusted Insura欧洲杯开户平台nce Company sent staff to check on the spot of accidents, Dedicated evidence material。
    Article 15  18746-18759, Insured or legal beneficiaries hold re欧洲杯开户平台levant materials to the service outlet to declare accidental damage payment。 Insured or legal beneficiaries can entrust others to declare on behalf of others。
    Article 16  Insured 欧洲杯开户平台or legitimate beneficiaries should provide social security cards or medical insurance cards, Payment certificate as an accidental damage。
    Article 17  欧洲杯开户平台Insured applicants apply for accidental injury medical expenses, The following materials should be provided:
    ( 1) Accident identity certificate;
    ( 2) 欧洲杯开户平台A copy of the outpatient medical records or a copy of the hospital medical records and a diagnosis certificate;
    ( 3) Original bill of medical expens欧洲杯开户平台es、 Cost list and prescription;
    ( 4) Certificate of accident issued by relevant departments;
    ( 5) Transfer payment authorization letter。
    Article 18  欧洲杯开户平台Insured applicants apply for accidental disability payment, The following materials should be provided:
    ( 1) Accident identity certificate;
    ( 2) A cop欧洲杯开户平台y of the outpatient medical records or a copy of the hospital for medical records;
    ( 3) Disability appraisal report issued by a qualified appraisal agency;
    ( 4) Certificate of acc欧洲杯开户平台ident issued by relevant departments;
    ( 5) Transfer payment authorization letter。
    Article 19  The legal beneficiary applies for an accidental death p欧洲杯开户平台ayment, The following materials should be provided:
    ( 1) Accident identity certificate;
    ( 2) A copy of the outpatient medical records or a copy of the 欧洲杯开户平台hospital for medical records;
    ( 3) Medical Certificate of Death Medical Certificate of Residents who indicate the cause of death or forensic identification letter;
    ( 4) Certifica欧洲杯开户平台te of accident issued by relevant departments;
    ( 5) Legal beneficiary identity certificate;
    ( 6) Proof of the relationship between the legal beneficia欧洲杯开户平台ry and the accident;
    ( 7) Transfer payment authorization letter。
    Article 20  The staff of the service outlet after receiving the application material欧洲杯开户平台s, For the application subject and the materials,, It should be accepted, and inform the claims process。 Not in compliance with relevant regulations, It should be notifi欧洲杯开户平台ed in writing and will not accept the decision。
    Article 21  After the application is accepted, Insured or legal beneficiaries, under the guidance of staff, F欧洲杯开户平台ill in《 Tianjin Basic Medical Insurance Accidental Insurance Substance Insurance Calculatory Application Form》、《 Tianjin Basic Medical Insurance Accid欧洲杯开户平台ental Insurance Calculating Calculatory Information Transmission Filters》( Sanlian Refining), Documents for medical expenses、 Disability Appraisal Rep欧洲杯开户平台ort、 Death Certificate and other materials according to the date、 Category category( Outpatient Clinic、 Hospitalized or hospitalized、 Emergency Observation, 欧洲杯开户平台etc.) Paste to《 Tianjin Basic Medical Insurance Accidental Insurance Calculating Calculatory Information Transmission Filters》, Signature confirmation。
    Article 22  20110-20112、 The 欧洲杯开户平台staff of the township service outlets shall transfer the claims declaration materials to the comprehensive service outlet within the acceptance of th欧洲杯开户平台e day after acceptance, Summary from comprehensive service outlets to report to the market service center uniformly collected storage。 After completin欧洲杯开户平台g the work of reviewing and information entry, Audit payment by Toto Insurance Company。
    Article 23  Trust insurance company shall make insurance liab欧洲杯开户平台ility for insurance liability within five days, Complex situation, It should be approved within 30 days。 belonging to the insurance liability, Trusted 欧洲杯开户平台Insurance Company will send the payment information to the designated Digai Bank, Delivery banks allocated funds to the insured or the legal benefici欧洲杯开户平台ary designated account; Not belonging to insurance liability, Emphasize to the insured or the legal beneficiary within three days after the review is 欧洲杯开户平台completed《 Tianjin Basic Medical Insurance Accidental injury additional insurance will not be notified for claims》。
    Article 24  Insured cases of acci欧洲杯开户平台dental injury medical expenses, Pay it at one time by the entrusted insurance company in accordance with the prescribed standards, Among them, 欧洲杯开户平台the part should be borne by the Basic Medical Insurance Fund, Pay on behalf of the trustee insurance company, ​​Settlement with the Municipal Social Security Center。
    Article 25  A欧洲杯开户平台n accidental damage occurred in the insured, If the application has not been filed within two years from the day of the accident,, It is deemed to be automatic欧洲杯开户平台ally abandon this accident damage payment requirements。
    Article 26  Participants participating in other similar commercial insurance at the same time欧洲杯开户平台, Payment by accidental injury insurance funds first, Then the relevant insurance company will follow the insurance contract( Agreement) agreed payment。
    Article 27  The insured pe欧洲杯开户平台rson treats accidental injuries and diseases at the same time, Accidental injury medical expenses are paid by accidental injury insurance funds, Disea欧洲杯开户平台se medical expenses are paid by basic medical insurance funds。
    Task Insurance Company should issue《 Tianjin Basic Medical Insurance Accidental injury 欧洲杯开户平台additional insurance medical expenses do not pay the bright order》, Together with the bill( Social Security News Nuclear Union) Original returned ins欧洲杯开户平台ured, The insured person will declare separately in accordance with the basic medical insurance reimbursement procedures。

    Chapter 6  Insurance Payment and Standards
    Article 28  Acci欧洲杯开户平台dental damage payment standards shall make opinions with the municipal financial department with the municipal financial department, Determined after 欧洲杯开户平台being approved by the Municipal People's Government。 The operation of the system of economic and social development and accident insurance insurance, 欧洲杯开户平台Report the Municipal People's Government for approval。
    ( 1) Accidental injury medical expenses payment。 Medical expenses below the certain standard of 欧洲杯开户平台accidental damage due to accidents, Funding from accidental damage insurance according to70% Payment of Payment; Inpatient medical expenses exceeding 欧洲杯开户平台this standard,21112-21138。
    21164-21175、21176-21180、21181-21196,21197-21213。
    Insured people have accidental injuries in different places, Its inpatie欧洲杯开户平台nt medical expenses are included in the scope of accident insurance insurance。 Insured people have accidental damage in this city, It really needs to 欧洲杯开户平台be treated for treatment, According to the relevant procedures for the transfer of basic medical insurance referrals, The trustee insurance company is 欧洲杯开户平台reviewed and handled。
    ( 2) accidental disability payment。 The insured person's physical disability due to accidental damage is identified as a level 欧洲杯开户平台1 to 4, Pay at one time according to the level of disability。 Disability levels according to the China Insurance Regulatory Commission《 About continui欧洲杯开户平台ng to use〈 Personal Insurance Disabled Disables and Insurance Payment Percents〉 Notice》( Insurance Supervision[1999]237 No.) Execution。
    ( 3) Unexpecte欧洲杯开户平台d death payment。 The insured person died accidentally, Pay the legal beneficiary at one time in accordance with the prescribed standards。

    欧洲杯开户平台Chapter 7  Entrusted Management Agreement
    Article 29  Municipal Human Resources and Social Security Department signed a commission management agreeme欧洲杯开户平台nt with the entrusted insurance company。 Trusted Insurance Company shall strictly manage funds in accordance with the agreement, Provide insurance pay欧洲杯开户平台ment and other services to the insured。
    Article 30  The content of the entrusted management agreement includes basic terms and liability clauses。 Bas欧洲杯开户平台ic clauses mainly clear the scope of guarantee、 Contract validity、 Insurance applications and payment basic matters; Responsibility clauses mainly cle欧洲杯开户平台ar insurance liability、 Responsibility exemption and other content。
    Article 31  The entrusted insurance company shall pay the relevant fee to the ins欧洲杯开户平台ured or the legal beneficiary in strict accordance with the agreement, and report the accidental injury insurance in writing to the municipal human an欧洲杯开户平台d social security department and the municipal social security center in writing.。
    Article 32  Municipal Social Security Center can re-review the cos欧洲杯开户平台ts paid by the Basic Medical Insurance Fund, Do not settle for expenses that do not meet the scope of payment。
    Article 33  Municipal Human Resources 欧洲杯开户平台and Social Security Department's Supervision Agreement Performance, Trusted Insurance Company failed to perform correctly in accordance with the agree欧洲杯开户平台ment, Should bear the liability for breach of contract, If the plot is serious, you can terminate the agreement in advance。

    Chapter 8  Affiliated rules
    Article 34  Insured or legal be欧洲杯开户平台neficiaries and trustee insurance companies due to disability identification、 The cause of the death of residents is determined to be controversial, Y欧洲杯开户平台ou can ask for arbitration or filed a lawsuit with the people's court with the district and county arbitration committee。
    Article 35  This regulation 欧洲杯开户平台is self-2011 Year1 month1 Implementation from the day。 Municipal Human Resources and Social Security Bureau、 Municipal Education Commission、 Municipa欧洲杯开户平台l Finance Bureau《 Notice on the establishment of a student's unexpected injury insurance system》( Paid of Jinren〔2009〕18 No.) Abolition at the same time。

 

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