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  • 學位論文

健康保險理賠風險因子分析

A Study on Claim Risk Factors of Health Insurance

指導教授 : 何佳玲

摘要


本研究以某壽險公司個人醫療保險附約完整銷售期間1999年至2017年底1,680,898筆投保資料及2010年至2017年底期間實際發生住院醫療理賠案件185,835筆進行實證研究,研究方式以敘述性統計、Logistic迴歸與普通最小平方法迴歸分析被保險人人口因素、就診因素、與醫療險理賠率、理賠天數、理賠金額之相關性,且本研究將與理賠相關之就診因素特別列入醫院座落位置、醫院等級及就診疾病碼等進行探討。依實證結果顯示被保險人人口因素,保額、性別、投保年齡、婚姻狀況、繳別、承保條件、教育程度、職業類別變數與理賠發生率、理賠天數、理賠金額之間存有顯著關聯。此外以被保險人居住地區及醫院座落地區而言,以北部相較於其他地區理賠金額為高。而非都會區的理賠率、理賠天數及理賠金額相對較低。醫院等級以醫學中心的理賠天數較多,但觀察理賠金額則以基層醫療院所較高。就診疾病碼以精神疾病、神經系統疾病、循環系統疾病的理賠天數較多,此外贅生物為惡性、精神疾病、妊娠分娩和產後、肌肉骨骼系統疾病、先天畸形的理賠金額較高。因此本研究提出建議核保及理賠管理政策、開發特定疾病商品、因應醫療利用習慣改變行銷策略,期望能有效防止不當理賠,促進保險業持續穩健經營。

並列摘要


To evaluate the risks of information asymmetry and adverse selection, this empirical study included 1,680,898 insureds’ information which were registered in the full sales period from 1999 to 2017 and the 185,835 claim which claimed actual hospitalization from 2010 to 2017. In this study, the elements of insured population, the factors of seeing doctors, the rate of claims, the days of claims, and the payment of claims were thoroughly analyzed with the descriptive statistics, the Logistic regression and OLS models. The factors of treatment reasons which usually brought in a claim, were meanwhile, particularly discussed with the geographic information of hospitals, classification of hospitals, and the code of ICD-9-CM. After analysis is found that the claim rate, claim days and the claim payments were empirically revealed a high relevance with the elements of insured population, such as the insuance amount, the insured gender, the insured age, the insured state of marriage, the premium type, the insured conditions, the education of insured, and the insured occupation classes. Furthermore, compared with other areas, the northern Taiwan has proposed higher claim payments in average if we look into the geographic information of insured habitation and hospitals. On the contrast, the claim rate, the claim days and the claim payments were comparatively low in the non-metropolitan areas. When it comes to the hospital classification, it comes up with longer claim days in medical centre and much claim payments in Clinics. As far as the ICD-9-CM was concerned, there are three codes which claim longer days, and they are mental and behavioral disorders, diseases of the nervous system, and the diseases of the circulatory system. Mentioning the factors of high claim payments, the top five factors are malignant neoplasms, mental and behavioral disorders, pregnancy, childbirth and the puerperium, diseases of the musculoskeletal system and connective tissue, congenital malformations. Above all, this essay proposes the improving suggestions in underwriting and in the management of claim. It also gives words in producing new certain medical insurance. It is expected to adjust the marketing strategy upon the actual medical use patterns, and it is also expected to put an end to improper claim and moreover to achieve the insurance company balance of payments and performance.

參考文獻


一、論文文獻
1.李宏銘,2004年,健康行為變數與終身型住院醫療保險之關係,國立高雄第一科技大學風險管理與保險系碩士論文。
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3.吳伊平,2011,健康狀況認知及個人健康行為與醫療門診次數關係之探討,佛光大學經濟學系碩士論文。
4.林均芳,2011,台灣環境汙染與疾病盛行率之關連性探討,長庚大學資訊管理學系研究所碩士論文。

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