医疗损害赔偿案件中基本医疗保险追偿实现的体系化建构

Systematic Construction of Basic Medical Insurance Recovery in Medical Damage Compensation Cases

摘要: 《社会保险法》第三十条规定基本医疗保险基金在不能确定第三人或第三人不支付医疗费时可以先行支付，先行支付后享有追偿的权利。实践中，医疗损害赔偿案件往往涉及计算损害赔偿时是否应当扣除先行支付的医疗费用问题，对此各地法院判决意见不尽相同。综合搜索结果，司法实务对此类案件的观点分为“严格区别社会保险与侵权责任，不扣除已支付医疗保险费用”与“社会保险与侵权责任的功能一致，扣除已支付医疗保险费用”。本文通过检索梳理相关案例，总结不同处理方式的内在原因。通过分析原因并结合我国现行规定与各地医疗保险经办机构的实际做法，寻找在实务操作中出现的追偿困境，并归纳出实务操作中存在的追偿义务主体不明晰、结算方式不明确以及医保追偿信息传递的不通畅等问题。综合基本医疗保险所具有的补偿性质以及司法裁判的考量因素，理清医疗损害赔偿与基本医疗保险之间的关系。从二者内在理论基础的一致性出发，在诉讼程序上引入医疗保险机构作为诉讼参与人、通过扩大解释《社会保险法》的适用范围明确结算方式以及将公益诉讼作为医疗保险基金的信息畅通与利益保障，从实体和程序的两个层面建构医疗保险追偿实现体系。

Abstract: Article 30 of the Social Insurance Law stipulates that the basic medical insurance fund may make payment in advance when it is uncertain whether a third party or a third party will not pay medical expenses, and has the right to recover after making the payment in advance. In practice, medical injury compensation cases often involve the issue of whether the medical expenses paid in advance should be deducted when calculating injury compensation, and the judgments and opinions of courts in different regions vary. Based on the comprehensive search results, the judicial practice’s views on such cases are divided into “strictly distinguishing between social insurance and tort liability, without deducting paid medical insurance fees” and “the function of social insurance and tort liability is consistent, deducting paid medical insurance fees”. This article summarizes the underlying reasons for different handling methods by searching and sorting out relevant cases. By analyzing the reasons and combining with the current regulations in China and the actual practices of medical insurance agencies in various regions, we aim to identify the recovery difficulties that arise in practical operations, and summarize the problems of unclear recovery obligations, unclear settlement methods, and poor communication of medical insurance recovery information in practical operations. Clarify the relationship between medical injury compensation and basic medical insurance based on the compensation nature of comprehensive basic medical insurance and the considerations of judicial judgments. Starting from the consistency of the internal theoretical foundations of the two, introducing medical insurance institutions as litigation participants in the litigation process, clarifying settlement methods by expanding the scope of application of the Social Insurance Law, and using public interest litigation as information flow and interest protection for medical insurance funds, constructing a medical insurance recovery implementation system from both entity and procedural levels.