Chapter IV Insurance Benefit Payments
Section 4 Occupational Accident Insurance Medical Benefits
After the approval of the central competent authority, the insurer may delegate the management of the payments of occupational accident insurance medical benefits to the National Health Insurance Administration, Ministry of Health and Welfare(hereinafter referred to as "NHIA"). The contract of delegation shall be drawn up by the insurer and the Bureau of National Health Insurance and submit to the central competent authority and the central health and welfare competent authority for review and approval.
After the insurer delegates the management of the payments of occupational accident insurance medical benefits to the NHIA, if the insured persons suffering from occupational injuries or occupational diseases, they shall apply to the medical service institutions affiliated with the National Health Insurance Program for treatment and diagnosis. With the exception of other regulations stipulated in the Act and these Regulations, the medical payments paid by the insurer shall be executed pursuant to the related regulations of the national health insurance program.
Upon applying for outpatient treatment or hospitalization treatment of occupational injury or disease, the insured person shall hand in a clinic note of occupational injury or disease or a letter of application for hospitalization treatment produced by the insured unit, and produces the national health insurance card and the ID card or other identity certificates for verification. In case of failure to submit the foresaid documents or in case the submitted documents don't meet the requirements, the national health insurance medical service institution shall deny the patient registration for diagnosis and treatment as an insured person.
In the event that the insured persons cannot submit or submit for review the related required documents due to the facts that they have not received the occupational injury or disease outpatient medical treatment bills, hospitalization application forms, national health insurance cards, or seeking emergency treatments for injuries or diseases, they shall prepare and submit other related documents that can verify their identities and proclaim they are in the possession of labor insurance status, and proceed to register and receive medical treatments. Under such circumstances, the medical service institutions affiliated with the national health insurance programs shall provide medical services , receive insurance medical expenses , and issue receipts to the persons seeking medical treatments. In case the insured persons obtain and submit the required documents within ten days (excluding regular days off) or before hospital discharge after the date they are admitted for medical treatments, the medical service institutions affiliated with the national health insurance program shall refund the paid insurance medical expenses.
In the event that the insured persons are unable to provide the necessary documents within the ten days or before hospital discharge after receiving medical treatments as stipulated in the preceding article as the result of any circumstances not of their own faults, they shall prepare and submit the occupational injury or disease outpatient medical treatment bills or hospitalization application forms and the receipts of medical expenses prepared and issued by the medical service institutions affiliated with the national health insurance programs, within six months from the date of receiving outpatient medical treatment or the date of releasing from hospitalization, to the insurer responsible for the jurisdictional districts to apply for reimbursement of the paid medical expenses.
Upon receipt of the insured persons' occupational injury or disease outpatient medical treatment bills, the medical service institutions affiliated with the national health insurance program shall attach them to the medical histories of the insured persons and preserve them for reference. Upon receipt of the occupational injury or disease hospitalization application forms, they shall fill out in detail the verification portions of the application forms and submit them within three days to the insurer for review and examination.
After the insurer review the applications for hospitalization referred to in the preceding paragraph and decides that they are not qualified as occupational injuries or diseases, it shall notify the NHIA, the medical service institutions affiliated with the National Health Insurance Program, insured units and the insured persons.
In the event that the insured persons are hospitalized several times with the same occupational injuries or diseases, the total number of days of food expenses as provided for in Subparagraph 4 of Paragraph 1 of Article 43 of the Act shall be counted from the first day of hospitalization and calculated in combine every six months.
The standards for payments of the food expenses referred to in the preceding paragraph shall be drawn up by the central competent authority with the central health and welfare competent authority.
In the event that the occupational injury or disease hospitalization application forms issued by the insured unit contain any incomplete information, errors, or the whole procedure is not complete, after two notifications from the insurer to make the necessary corrections within certain time limits but to no avail, thus creating a situation that the insurer cannot make proper assessments and payments medical benefits, the insurer shall not pay the benefits.
After the implementation of the National Health Insurance Program, the hospital rooms belong to the Government Employees' Insurance Programs referred to in Subparagraph 5 of Paragraph 1 of Article 43 of the Act shall be designated as the insurance rooms belong to the National Health Insurance Program.
An insured person meeting one of the following conditions may file an application through the insured unit to the insurer to apply for medical expense reimbursement:
1.Insured person received treatment in a local hospital or clinic for occupational injury and/or disease that took place outside of the territories covered by this Act.
2.Insured person received emergency care treatment in a hospital or clinic that is not designated by the National Health Insurance program for occupational injury and/or disease that took place in the territories covered by this Act.
The certifying documents, reimbursement deadline, reimbursement basis, procedures to follow, and scope of emergency care in relation to the aforementioned application for medical expense reimbursement shall be applicable mutatis mutandis to the Regulations for National Health Insurance Reimbursement of the Self-Advanced Medical Expenses.