国家金融监督管理总局数据显示，2024年，我国健康险保费规模已逼近万亿大关，基本接近有10亿人参 加的居民基本医保的总体筹资水平，增长速度也逆转了前三年放缓的趋势。但当前，最需要保障的市场 ——带病人群，仍然被系统性地排除在外。 近年来，以百万医疗险为代表的健康险产品不约而同地放宽既往症限制，甚至"免健康告知"的产品也不 在少数。在董佳所经手的客户中，带病体或者为父母配置健康险的客户大致占八成，而这些客户从投保 到理赔，心情往往犹如"过山车"——投保前"挑花眼"，核保时却仍可能被拒之门外，即便投保成功，还 面临"可保不可赔""不承诺续保"等风险。 健康险保费规模近万亿，带病人群为何"可保难赔"丨"病有所保"大调研 作者：吴斯旻 "产品数量过多还是过少？"从事商业健康保险(下称"健康险")销售4年后，董佳日益受到这一问题的困 扰。 艾社康近期发布的一份关于多层次医疗保障研报也显示，中国近4亿人属于带病人群，他们贡献了约 60%的医疗支出，但其贡献的商保保费占比仅为5%左右。这一背景下，创新药械企业发现，商保"放 量"的空间似乎仍然窄小。 上述情况正倒逼健康险行业转型。"近期，金融监管部门号召健康险公司做了几次行 ...

2025.08.31 本文字数：2889，阅读时长大约5分钟 作者 |第一财经 吴斯旻 【编者按】 经历了三年的增长放缓后，中国商业健康保险市场在去年展现出回暖态势，并有望在今年突 破万亿规模大关。但当市场重拾增长动能后，结构性转型依然迫在眉睫——从"保健康人"转 向"保人健康"。 "保人健康"即让商保覆盖数量庞大的、患有既往症或慢性病的"带病体"人群，而"带病体"保 险的成长既事关多层次医疗保障体系构建，也事关创新药发展。 今年8月，上海率先发布《关于促进商业健康保险高质量发展助力生物医药产业创新的若干 措施》（下称"新十八条"），提出"鼓励保险机构按照风险可控、商业可持续原则，将老年 人、既往症和慢性病人群纳入保障范围"。 "带病体"保险市场的发展相较于传统健康险产品更需要政策端的支持。那么，上海是如何集 多部门合力，推动市场差异化创新？当更多"带病体"被纳入商保保障范围内，对于创新药械 企业销售"放量"作用几何？从个险到团险，从普惠性保险到中高端保险，上海如何构建多层 次多元化的健康险市场？第一财经近期就这些问题展开调研和探讨。 （2024年，惠民保和百万医疗险贡献了商保对创新药械支付的近四成金额，支付 ...

Core Insights - The Chinese commercial health insurance market is showing signs of recovery after three years of slowdown, with expectations to surpass the trillion yuan mark this year [1] - A structural transformation is necessary, shifting from "insuring healthy people" to "insuring people's health," particularly focusing on the large population with pre-existing conditions or chronic diseases [1] - Shanghai has introduced measures to promote high-quality development of commercial health insurance, encouraging the inclusion of elderly and chronic disease patients in coverage [1] Group 1: Market Dynamics - In the past year, innovative drug companies have expressed interest in expanding their market through group insurance channels, despite the group insurance market being larger but facing challenges such as low reimbursement for common diseases [3][4] - The group insurance market has a significant potential for covering innovative drug costs, with the annual premium scale exceeding 100 billion yuan, accounting for nearly 30% of the commercial medical insurance market [4][5] - The contribution of group insurance to the payment for innovative drugs is currently low, at around 10 billion yuan, indicating a gap in coverage for specialized drugs [5] Group 2: Challenges and Opportunities - The group insurance market is experiencing pressure from rising claims and a slowdown in premium growth, with a compound annual growth rate of about 11% from 2018 to 2023, significantly lower than that of individual insurance products [6][7] - The average claims ratio for group insurance is expected to remain high, around 80%, due to increased healthcare utilization and employee health awareness [8] - There is a pressing need for reform in group insurance products to accommodate innovative drug coverage, as current structures may lead to overuse of benefits for minor ailments [9][10]

"当命运的风暴袭来，总有一双手，默默托起你摇摇欲坠的勇气。"——对于乳腺癌复发患者H女士(化 名)而言，这份"托举"的力量，来自一份保险承诺。一份仅用5个工作日到账的10.5万元理赔款，为乳腺 癌复发患者H女士(化名)的抗癌之路注入了一剂"强心针"。从确诊到复发，从手术到理赔，这场持续6年 的生命拉锯战中，保险不仅成为经济支撑，更化作直面病魔的底气。 2024年6月，命运再次考验H女士(化名)。复查结果显示乳腺癌已发生肝转移，治疗费用的压力裹挟着复 杂的情绪极速涌来。担忧之际，她想起那份尘封的保单，于7月1日向保险公司提交了理赔申请。令她惊 喜的是，保险公司仅用5个工作日便完成审核，10.5万元理赔款迅速到账。"从提交材料到收到钱，比我 想象中快太多！"H女士(化名)感慨道，"抗癌是场持久战，但保险让我有了更多选择权。" 2018年7月，38岁的H女士(化名)在体检中被确诊为左乳癌，病理类型为乳腺浸润性小叶癌，术后病理分 期为I期，LB型。手术切除了病灶，却未能消散她心中的恐惧："如果复发怎么办？家庭经济能否承 受？"这份担忧，成为她抗癌路上挥之不去的阴霾。 2022年8月，在家人支持下，H女士(化名)首次投 ...

Core Viewpoint - The commercial health insurance industry is increasingly focusing on insurance products for patients with pre-existing conditions, particularly in the context of disease recurrence insurance, which is expected to see significant growth by 2025 [3][4]. Group 1: Market Trends and Developments - The disease recurrence insurance market has seen new product launches, such as the "Good Effect Insurance" series by Taikang Online, which expanded coverage from breast cancer to include lymphoma and lung cancer [5]. - In 2024, the health insurance premium income reached 977.4 billion yuan, marking an 8.2% growth, but the industry is facing stagnation due to market saturation among healthy individuals [6][7]. - The concept of insuring patients with pre-existing conditions is still relatively new and unclear, with estimates suggesting that the market could be around 50 billion yuan, primarily driven by supplementary medical insurance and high-end medical insurance [9]. Group 2: Product Insights - The most notable products in the disease recurrence insurance category are breast cancer recurrence insurance, which has become the largest single product in this segment, and million medical insurance that covers pre-existing conditions [12]. - The "Zhongminbao" product by Zhong An Insurance achieved rapid success, collecting 1.4 billion yuan in premiums within ten days of launch, indicating strong market demand [12][13]. Group 3: Sales and Distribution Challenges - The primary challenge in selling pre-existing condition insurance lies in distribution channels, as traditional channels are primarily focused on healthy individuals, making it difficult to reach the target demographic [16]. - Collaborations with hospitals are being explored to facilitate access to patients, but these partnerships face regulatory and operational uncertainties [17][18]. - Alternative sales strategies include leveraging pharmaceutical companies' distribution networks, which have shown some success in the market [18]. Group 4: Financial Performance and Risk Management - Currently, the existing pre-existing condition insurance products have not reported losses, but concerns remain regarding the maturity of cost control capabilities [21][22]. - The risk of high claims in million medical insurance products remains a concern, particularly for those that initially relaxed underwriting standards to attract customers [23][24]. - Insurers are employing traditional cost control methods, such as increased premiums and strict underwriting, to manage risks associated with these products [24][25].

Core Viewpoint - The article highlights the recognition of Taikang Online's "Good Effect Insurance - Pink Guardian (Drug-Free Version)" as an innovative insurance product in the field of breast cancer recurrence protection, showcasing the shift in commercial health insurance from "insuring healthy people" to "insuring people's health" [1][3]. Group 1: Product Innovation and Features - Taikang Online launched the "Good Effect Insurance - Pink Guardian" in 2022, providing specialized protection for post-operative breast cancer patients, addressing a gap in the market for insurance covering pre-existing conditions [3][5]. - The upgraded "Drug-Free Version" offers dual protection through reimbursement and lump-sum payment, with a maximum reimbursement of 1 million for recurrence medical expenses and a one-time payment of 50,000 to 500,000 upon diagnosis of recurrence or metastasis [3][4]. - The product includes a dynamic special drug directory covering 58 innovative breast cancer drugs with a 100% reimbursement rate, and it extends medical service networks to 29 quality private specialty institutions and over 1300 DTP pharmacies [4][6]. Group 2: Market Demand and Strategic Positioning - The increasing incidence of breast cancer and the high medical expenses associated with recurrence highlight a significant protection gap in the market, driving demand for comprehensive health insurance solutions [5][6]. - Taikang Online's "Good Effect Insurance" series includes specialized coverage for various cancers, such as thyroid cancer, lung cancer, colorectal cancer, and lymphoma, demonstrating a commitment to addressing the needs of patients with pre-existing conditions [5][6]. - The company aims to create a full-cycle insurance system that integrates medical services, pharmaceutical resources, and financial solutions, enhancing service efficiency and patient care [6]. Group 3: Technological and Resource Integration - Taikang Online leverages its group medical and nursing system to establish a nationwide medical network, providing various medical services and home rehabilitation support [6]. - The company has developed a digital risk control system and an AI customer service platform, enhancing operational efficiency and risk management capabilities [6]. - The integration of commercial insurance with the pharmaceutical industry is seen as a key pathway to solving the protection challenges faced by patients with pre-existing conditions [6].

Core Viewpoint - The new "National Ten Articles" policy released by the State Council aims to enhance the development of the insurance industry over the next 5 to 10 years, focusing on improving health insurance service levels and expanding coverage, which presents new opportunities for the integration of commercial insurance and the pharmaceutical industry [1][2]. Group 1: Policy and Industry Trends - The new policy emphasizes high-quality development in the insurance sector, shifting focus from scale growth to quality, and aims to enhance risk prevention and regulatory oversight [1][4]. - The integration of commercial insurance with the pharmaceutical industry is seen as an inevitable trend, driven by the need for comprehensive health solutions and the potential for significant payment space in commercial insurance [1][4]. Group 2: Company Initiatives and Innovations - On the occasion of its 10th anniversary, Taikang Online hosted a forum to discuss the development paths for insurance products catering to individuals with pre-existing conditions, highlighting the importance of innovation in commercial insurance [1][4]. - Taikang Insurance Group is actively pursuing a comprehensive health ecosystem that addresses the needs of an aging population and the increasing demand for health services, aligning with the "Healthy China" strategy [2][4]. Group 3: Product Development and Market Needs - Taikang Online has developed a product system that covers the entire disease cycle, focusing on cancer patients with innovative insurance products like the "Good Effect Insurance" series, which has undergone multiple iterations to enhance accessibility to innovative drugs [6][7]. - The company aims to transition from being a mere financial payer to a health promoter, addressing the urgent needs of individuals in non-standard health conditions through a triad of good medicine, good drugs, and good services [6][7]. Group 4: Collaborative Ecosystem - The integration of commercial insurance with medical, health insurance, and pharmaceutical sectors is essential for creating a robust industry ecosystem, with various stakeholders emphasizing the need for collaboration to enhance service delivery and efficiency [7]. - Taikang Online is committed to exploring insurance solutions for individuals with pre-existing conditions, aiming to position commercial health insurance as a valuable payment entity within the pharmaceutical industry [7].

Core Insights - The article highlights the launch of a new medical insurance product, "All Insurance," which does not require health declarations and guarantees renewal for five years, addressing the insurance needs of individuals with chronic diseases [1][3][4]. Group 1: Product Features - "All Insurance" allows coverage for general pre-existing conditions, excluding five severe categories, thus enabling individuals with chronic diseases like hypertension and diabetes to obtain insurance [3][4]. - The product offers a coverage limit of 2 million yuan for general medical insurance and 200 million yuan for critical illness medical insurance, with additional benefits for specific treatments [3][4]. - The insurance guarantees renewal for five years, with the maximum renewal age set at 105 years, catering to the needs of the elderly population [4]. Group 2: Market Context - The current market for medical insurance often employs a "yearly throwaway" strategy for individuals with pre-existing conditions, leading to potential coverage gaps [4]. - Approximately 75% of individuals aged 60 and above in China suffer from at least one chronic disease, indicating a significant market for tailored insurance products [4]. Group 3: Service Enhancements - The product includes value-added services such as "one-code payment," "check-up green channel," and "hospitalization green channel," enhancing the overall user experience [6]. - The insurance expands its hospital network to include ten private hospitals, providing users with more healthcare options beyond public hospitals [5]. Group 4: Industry Impact - Waterdrop Insurance aims to redefine the risk boundaries for insurable individuals with chronic conditions, leveraging extensive data to improve underwriting processes [7]. - The collaboration with Deutsche Assistance Life Insurance reflects a commitment to innovation in health insurance, focusing on customer-centric solutions [8].