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About insurance benefits

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Health insurance provides various kinds of benefits when an insured person becomes sick or injured while not at work, as well as when someone gives birth or dies. These business services, including provision of medical treatment and payment of benefits, are all called “insurance benefits.”

POINT
  • Insurance benefits are health insurance benefits provided when an insured person becomes sick or injured while not at work.
  • Payments are limited to medical treatments for which insurance reimbursement is already nationally approved.

Payments when someone becomes sick or injured while not at work

If an insured person becomes sick or injured while not at work, he/she can receive the following medical treatments by submitting his/her health insurance card at the counter of a hospitals or clinic that accept health insurance.

  1. Medical examination
  2. Provision of medicines and items used for medical treatment
  3. Treatments, surgeries and other therapies
  4. Home medical care and nursing
  5. Hospitalization and nursing

Injuries at work or during commuting are covered separately by workers’ accident compensation insurance

Since health insurance benefits are intended to provide in cases of sickness or injury of an insured person when off work, injuries of an insured person at work or during commuting will be covered by workers’ accident compensation insurance. Please note that you cannot receive benefits if you have been made redundant.

* From October 2013, even if injuries incurred while on duty are exempted from workers’ accident compensation insurance payment, they will be covered by health insurance, except for injuries incurred while on duty as an officer of a corporate body (excludes corporate bodies with less than five employees).

In-kind benefits and cash benefits

There are two methods for providing insurance benefits if an insured person becomes sick or is injured. The first method is to provide medical care itself as a benefit, and the second method is to reimburse the cost of treatments. The method of providing medical care as the benefit is called “in-kind benefits,” and the method of providing cash as the benefit is called “cash benefits.”

Cases not covered by health insurance

Benefits covered by health insurance are limited to medical treatments whose safety and validity as treatment methods have been approved and for which insurance reimbursement is already nationally approved.

When health insurance cannot be used When health insurance can be used
Conditions such as freckles, bruises, pimples, moles, or underarm odor, etc., that have no adverse effect on work or daily life. Symptoms that need treatment
Conditions such as nearsightedness, farsightedness, astigmatic, squint, color blindness, etc., which cannot be corrected. Medical examinations, inspections, prescriptions for glasses when consulting insurance doctors for eyesight abnormalities
Cosmetic surgery Orthopedic surgery for treatment of injury
Medical checkups, lifestyle-related illnesses checkups, complete medical checkups Treatment proving to be necessary as a result of medical examination
Vaccination, preventive oral treatment Vaccination for tetanus when infection through a wound is possible
Normal pregnancy and childbirth Symptoms that need treatment such as pregnancy-induced hypertension, abnormalities of pregnancy
Elective abortion for economic reasons Elective abortion based on the Maternity Protection Law, excluding economic reasons

Cases when insurance benefits are limited

In the following cases, insurance benefits are limited even if an insured person becomes sick or injured when off work.

Limited wholly
(Excluding burial fee)
  • When an accident is intentionally caused.
Limited wholly or partially
  • When an injury is caused by fighting or inebriation.
  • When an insured person receives or attempts to receive insurance benefits by fraud or through other irregularity.
  • When an insured person refuses to answer questions or to be diagnosed directed by the Health Insurance Association.
Limited partially
  • When an insured person, without justifiable grounds, does not follow the directions of doctors.

* If an insured person is in a juvenile reformatory, penal institution or detention cell, insurance benefits will not be provided because of his/her eligibility for provision of medical treatment benefits at public expense.

How medical care expenditures are paid

After a health insurance card is submitted on taking medical treatment, the medical institution will make a monthly claim for the collective co-payments due from that health insurance association for medical treatments, along with claims on other societies.

If all the medical institutions and health insurance societies nationwide were to claim or pay out on every occasion when a person sought medical treatment, it would be a very complicated operation.

Therefore, charging and payment of medical care expenditures are conducted through review payment bodies including the Health Insurance Claims Review & Reimbursement Services. For this reason, claims for medical care reimbursement received by health insurance societies will be processed almost three months later, so benefits provided to insured people from their health insurance will be received three months after the month of the medical treatment.

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