Read Bigeng｜Correctly understand Hexin’s “fake diagnosis certificate” insurance fraud incident

The recent hot news about Hexin Obstetrics and Gynecology Department’s “fake diagnosis certificate” insurance fraud is not just for fun, but also for the doorstep. Take this opportunity to talk about the connection between having children and insurance.

■ Clarify two concepts

Before entering the discussion, there are two things that need to be clarified:

1・It is medical insurance in insurance

There are various types of insurance. The type of insurance involved in this case is "medical insurance" (covering hospitalization, surgery, out-of-pocket expenses...); another type of insurance related to childbirth is "women's insurance", which only concerns about safe birth, not delivery . In this way , you can apply for a "maternity allowance" after registering your account, which is an incentive .

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2. It only counts if you take out insurance before it happens.

It is not difficult to understand that insurance must be purchased " before " something happens, so planning must be completed " before pregnancy " to be safe.

Some people must want to ask: "In the early stage, I was pregnant but didn't know it. How to explain it?" This involves heart syndrome, which is too difficult. In practice, it is written in black and white, that is, the day when you go to the obstetrics and gynecology department for the first time and the doctor confirms that you are pregnant and has a diagnosis record (health insurance card/mother's handbook) is the watershed.

However, some people want to ask: "I only use a pregnancy test stick (or other signs), I suspect that I am pregnant, and I haven't seen a doctor yet. What's the explanation?" Firstly, as long as you don't say it, secondly, the evidence is wiped out, and thirdly, this "feeling" It may not be accurate, and it will all go back to the heart certificate, which is too difficult. Let’s go back to the “science” in the previous paragraph to make a decision.

■ Childbirth and medical insurance, three situations

There are three possible situations when a child is born:

1・Natural childbirth

It must be understood that natural childbirth is not a disease (it is very important, please recite it silently three times). Since it is not a "disease", it is not covered by medical insurance and cannot be paid .

The opposite of natural childbirth is (artificially performed) caesarean section, which will be discussed in detail next.

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2・Voluntary caesarean section

Whether it is because of fear of pain or because of the auspicious timing given by the fortune teller, it can be generally called a " voluntary " caesarean section. To put it more politely, this is an "unnecessary" medical behavior and no compensation will be paid .

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3. Etiological caesarean section

Carrying on from the above, a caesarean section must be "necessary" for medical reasons in order to be eligible for compensation. To put it in an easy-to-understand way, it is called " causal " caesarean section. Commonly heard caesarean sections include malposition of the fetus and umbilical cord wrapped around the neck... You might as well start from insurance . The corresponding terms for salvage in the Development Center database are found in the "Exclusions" paragraph, reference is as follows:

To help everyone review, we also condensed all the above discussions into a slide and share it.

■ Epilogue: How to treat the Hexin insurance fraud case

With the above background knowledge, let us fight against falsehoods and seek truth.

The so-called "fake" should mean that the client clearly performed a " voluntary (non-essential medical act) " caesarean section, but it was not recorded truthfully. Instead, it was replaced with a " causal (necessary medical act) " caesarean section. As long as it is in the medical record Change the way of expression from the one on the medical certificate, and it will become a different kind of "truth" with just a little effort.

Is the reason for the clinic’s performance improvement? Or can’t stand pressure/pleasure from customers? Without making too much speculation, what is certain is that the Hexin insurance fraud incident only reflects the tip of the iceberg of this phenomenon.

This article can simply be regarded as a piece of popular science.

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