A woman in Chongqing bought a commercial insurance suddenly terminated her contract, which led to a local hospital fictitious of her hospitalization record and defrauding her medical insurance payment. Afterwards, she sued the other party and demanded that her false medical records be removed, and she lost one after another. On July 12, the reporter learned that under her report, the local medical insurance bureau fined the hospital.
Chongqing Yubei District Medical Insurance Bureau. Respondent provided by
A woman was terminated for purchasing commercial insurance
This woman is called Xie Bing (pseudonym), 49 years old, from Yubei District, Chongqing.
She told reporters that on August 15, 2018, she signed an "Insurance Contract" with Taiping Life Insurance Co., Ltd., , which mainly stipulated that she would purchase the company's three types of insurances, namely Taiping Fulu Kangrui 2018 Lifetime Major Illness Insurance, the insurance period is life, the payment period is 20 years, the standard premium is 3,360 yuan, and it is paid annually.
Taiping Medical Worry-free Medical Insurance, the insurance period is 1 year, the payment period is 1 year, the standard premium is 1,488 yuan, and it is paid annually. Taiping Aiwuyou Comprehensive Accident Injury Insurance, the insurance period is 1 year, the payment period is 1 year, the standard premium is 260 yuan, and it is paid annually. The company issued her an electronic insurance policy, which took effect on August 16, 2018.
Xie Ping recalled that on August 22, 2019, she was hospitalized for 5 days after being ill. Taiping Life Insurance Co., Ltd. based on her application, claimed 2,093.37 yuan on her according to Medical Worry Insurance. At the same time, she told her that because she did not inform the facts that it affected the underwriting decision, the insurance contract was terminated from the date of the compensation (no refund).
On September 27 of the same year, Taiping Life Insurance Co., Ltd. sent her a "claim review notice", saying that during the review, she learned that she had " brain blood supply insufficient and ulnar fracture" before taking out insurance. Because she did not truthfully inform these matters when taking out insurance, after the insurer re-understood, it was decided that the insurance contract, Taiping Fulu Kangrui, 2018 lifetime major disease insurance period, was 630 yuan, and the insurance contract, Taiping Medical Worry Medical Insurance, terminated the insurance contract.
sued the hospital for requesting the removal of false medical records and archives information, losing one after another,
The commercial insurance he purchased was suddenly terminated, and Xie Ping couldn't figure it out.
Later, when she went to the insurance company to inquire about the situation, the staff immediately checked in the medical system and told her that she had a history of hospitalization at Chongqing Jinyi Hospital Co., Ltd. (hereinafter referred to as Jinyi Hospital) from March 24 to March 28, 2017.
Xie Ping said that she had never been hospitalized in the hospital for treatment, and her signature and diagnosis results in the medical records retained by the hospital were not true.
She told reporters that she had repeatedly asked the hospital to withdraw her medical history, but the other party shirked the responsibility for various reasons, so she reported it to the Yubei District Medical Insurance Bureau.
She also sued Jinyi Hospital in a lawsuit against the Yubei District Court of Chongqing City, requesting that the other party immediately revoke and clear her false medical records and information in the hospital and the medical system, and ordered the other party to compensate her for her property losses of 8,476.43 yuan, and estimated property losses of 10,710 yuan.
On September 4, 2020, the Yubei District Court filed a case and held a public trial on November 9 of the same year.
Xie Ping called the police to the Xiantao Police Station in Yubei District.
During the trial, Jin Yi Hospital, as the defendant, argued that Xie Ping's lawsuit was a form-based lawsuit, and his lawsuit did not have the interest in prosecution, and that his claim was not within the jurisdiction of the court, so he should rule to dismiss his lawsuit. Her medical insurance card has not been lost and reissue. Even if the signature on the medical record is not done by her, it may be signed by her close relatives. It cannot prove that she has not been to the hospital for treatment. "Xie Ping claims that we forge medical records and demand compensation, without facts and legal basis." After the trial, the Yubei District Court held that according to the current basic medical insurance reimbursement system in my country, when a patient uses basic medical insurance to reimburse medical expenses after discharge after hospitalization, he must use his medical insurance card to swipe the card and provide the patient's identity information. That is, when the medical expenses of basic medical insurance must be reimbursed, he must have both the patient's hospitalization medical record and his medical insurance card to be reimbursed. The patient's medical record information is provided by the hospital. The hospital cannot settle the basic medical insurance only if the patient's medical record information is only available.
The hospital believes that according to the settlement form of Chongqing Basic Medical Insurance’s personal medical expenses, the plaintiff Xie Ping reimbursed her basic medical insurance for hospitalization at Jinyi Hospital on April 1, 2017. Her medical insurance card will definitely be used in this reimbursement, but she did not provide evidence to prove that her medical insurance card was lost. Therefore, when the plaintiff’s medical insurance card was kept by her, she should be aware of the fact that the medical insurance card was used during this reimbursement process, and reimbursement will inevitably provide corresponding medical records. Therefore, the existence of the medical records should also be informed, but she did not raise any objections at the time, so the defendant’s behavior does not constitute infringement, and she has no right to require the defendant to bear tort liability.
Regarding the property damage claimed by Xie Ping, the reason why Taiping Life Insurance Co., Ltd. terminated the insurance contract signed with her was not only because she did not inform her of insufficient brain blood supply before taking out the insurance, but also because she did not inform her of the ulnar fracture. There is no record of her ulnar fracture in the medical record, so it cannot be determined that there is a causal relationship between the defendant's issuance of the hospitalization medical record and the termination of her insurance contract. The hospital will not support her request for compensation for the property damage caused by this.
In December 2020, the Yubei District Court rejected her lawsuit in the first instance.
She was dissatisfied and appealed to the Chongqing No. 1 Intermediate Court, and was "dismissed and the original judgment was upheld."
Xie Ping was still dissatisfied and applied for a retrial to the Chongqing High Court, saying that the basic facts determined by the original judgment lacked evidence to prove the evidence, and the main evidence for the facts was forged, and the judgment harmed her legitimate interests. She hoped to apply for a retrial in accordance with relevant regulations.
On August 20, 2021, the court rejected her application for retrial.
In response to this, Xie Ping told reporters that her medical insurance card has always been kept by herself and she did not provide it to Jinyi Hospital at all.
Since this is the case, how did Jinyi Hospital reimburse medical insurance?
On the evening of July 13, 2022, a staff member named Jiang from Jinyi Hospital who had contacted Xie Ping at that time told reporters, "This hospital has been sold long ago. I have not participated in this matter. I don't know about the medical insurance card." After that, he hung up the phone quickly.
handwriting fingerprint identification found that the hospital was punished for fraudulent insurance
At the same time, in mid-June 2021, Xie Ping directly reported it to the Chongqing Medical Insurance Bureau with real name. Later, the report was handed over to the Yubei District Medical Insurance Bureau for processing. She requested a thorough investigation of Jinyi Hospital and conduct a judicial handwriting identification on the fake signatures on the medical records.
The Yubei District Medical Insurance Bureau said in her reply to Xie Ping that the bureau attached great importance to the issue she reported that "I did not see a doctor at Jinyi Hospital but had hospitalization records" and immediately instructed the relevant departments to investigate and deal with it.
Yubei District Medical Insurance Bureau investigated that Jinyi Hospital made up medical records.
The bureau said that they had contacted the judicial appraisal center of Southwest University of Political Science and Law to identify the signature and signature in the medical record she visited at Jinyi Hospital to determine the authenticity. The center's appraisal results show that the signature and signature on the medical record are inconsistent with her real signature and handwriting, which is forged. The medical record is fictional. The hospital's behavior violated the relevant content in the "Medical Insurance Service Agreement". The bureau has dealt with it that the illegal principal is 401.9 yuan and the liquidated damages are 2,009.5 yuan.
Relevant persons from the Yubei District Medical Insurance Bureau told reporters that they handled Jinyi Hospital in accordance with the "insurance fraud", "which is equivalent to defrauding the national medical fund ."
checked the handling results and reported the police
On the afternoon of May 11, 2022, Xie Ping went to the bureau to check the investigation and punishment results of Jinyi Hospital according to the previous agreement with the Yubei District Medical Insurance Bureau.
She told reporters that after she came to the Yubei District Medical Insurance Bureau, when she checked the copy of the processing results, she had a dispute with a deputy section chief named Li of the bureau. She was touched by the other party's chest, "causing varying degrees of damage to my body, and also causing me serious mental shock." After the incident, Xie Bing immediately called the police for help. After receiving the alarm, the police from Xiantao Police Station of Yubei District Public Security Bureau immediately rushed to the scene to investigate. After verification, it was found that Xie Ping had a dispute with the staff at the Yubei District Medical Insurance Bureau for reporting the insurance fraud in Jinyi Hospital. Later, the two parties had negotiated.
The deputy section chief named Li of Yubei District Medical Insurance Bureau told reporters that there was no physical contact between them at that time, and he did not touch Xie Bing's chest. After the incident, he was admonished and talked to the bureau for his attitude and made a profound review.
In a recording of the call provided by Xie Ping, the relevant person in charge of the bureau apologized to her, "I keep silent for this apology."
News in-depth:
Public welfare personnel say that the stubborn medical insurance fraud is in a state of consolidation and disease urgently needs to be deterred by law
Public welfare personnel who have been paying attention to the safety of medical insurance funds for a long time said that the routines of medical institutions fraud fraud are similar. Some hospitals with poor "business" try every means to obtain information of insured persons in batches and forge their hospitalization history, and make high cost insurance fraud.
He said that in recent years, the national medical insurance policy requires "there are people on the bed", and some hospitals have changed their strategies, organized special vehicles to pick up and drop off mild or asymptomatic elderly people in hospital, and even organized rural elderly or retirees to be hospitalized in beds in physical examination, recuperation, and shopping styles, so as to achieve the purpose of defrauding medical insurance funds.
He told reporters that for a long time, it is no secret that medical insurance funds were fraudulent, and regulators should pay attention to reporting on fraudulent insurance, and then follow the clues and find out to the end.
He said that the medical insurance fund is the life-saving money and life-saving money for ordinary people. The existing laws and regulations should refine the identification of insurance fraud. Sometimes the boundaries of "insurance fraud and violation" are blurred. The discretion of the medical insurance bureau staff is relatively loose. Some medical insurance frauds that require criminal responsibility are sometimes easily considered as violations of medical insurance contracts. The management model of medical insurance funds using cat and mouse games needs to be solved urgently, and the stubborn diseases of medical insurance fraud need to be effectively deterred by law. Huashang Daily reporter Shen Xiaodu Editor Chen Youmou
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