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National Health Insurance (Employer-sponsored Insurance)
Restriction of National Health Insurance Benefits
Restriction of Benefits for Intentional or Serious Fault
- If a person eligible for benefits falls under any of the following categories, the Service can cease the provision of benefits (Paragraph 1 of Article 53 of the National Health Insurance Act).
· Person is seeking benefits for the treatment of a condition caused intentionally or by a serious fault
· Person does not follow medical advice given by the Service or a medical institution intentionally or by a serious fault
· Person refuses to submit the documents and/or articles specified in Article 55 of the National Health Insurance Act, or evades questioning/diagnosis in accordance with Article 55 of the National Health Insurance Act intentionally or by a serious fault
· Person receives a benefit or compensation for a work-related illness, injury, or accident in accordance with other legislation
- If a person eligible for benefits receives a benefit or payment equivalent to an insurance benefit provided by the Service from the central government or a local government in accordance with other legislation, the Service deducts the value of such benefit or payment received from the benefits owed to that person (Paragraph 2 of Article 53 of the National Health Insurance Act).
Restriction of Benefits in the event of a Default on Premium Payments
- If an employer-sponsored insurance subscriber is in default on the monthly premium payment other than remuneration by more than one month, the Service may not provide benefits to the employer-sponsored insurance subscriber or his/her dependent until the payment amount in default is made. Regardless of the period for which a monthly premium payment is in default, if the total number of payments previously defaulted is less than 6 (payments defaulted on that have since been made are excluded from the total number of previously defaulted payments, and the duration of the defaults is not considered) or the income, assets, etc. of the employer-sponsored insurance subscriber or his/her dependent are below the criteria prescribed in Article 26 of 「Enforcement Decree of the National Health Insurance Act」, no restriction of benefits will be imposed (subparagraph 1 of Article 53(3) and subparagraph 2 of Article 69(4) of 「National Health Insurance Act」 and Article 26 of 「Enforcement Decree of the National Health Insurance Act」).
- If an employer is delinquent in paying the monthly insurance premium for an employee (subscriber) and the delinquency is attributable to the employee, insurance benefits for the subscriber and dependents may be suspended by the Service (Paragraph 4 of Article 53 of the National Health Insurance Act).
- Notwithstanding the above regulation, benefits may be provided if an installment payment of a premium in default is approved by the Service and the approved installment payment is made at least once. However, benefits may be suspended if a person approved to make installment payments defaults payment five times or more (if the number of installment payments approved under Article 53(1) of the National Health Insurance Act is less than five, referring to such number of installment payments) of the installment payments. (Article 53(5) of the National Health Insurance Act).
- A benefit received in a period during which no benefits are provided (hereinafter referred to as the "benefit suspension period") is only valid in the following cases (Paragraph 6 of Article 53 of the National Health Insurance Act).
· When a payment in default is made by the due date for the month in which the day marking two months after the Service notifies the insurance subscriber of having received benefits during a benefit suspension period falls
· When a defaulted payment for which installment payments have been approved is made more than once by the due date for the month in which the day marking two months after the Service notifies the insurance subscriber of having received benefits during a benefit suspension period falls (However, persons who were approved to make installment payments for a payment in default but miss more than five installment payments without a valid reason are excluded)