Core Insights - The medical insurance claims in 2024 exceeded 86 billion, with an average annual growth rate of 21% over the past decade [1][12][87] - The report highlights significant cases of high claims, including five cases with total payouts exceeding 3 million and eight individuals with over 100 claims [1][21] - The trend of "one-stop" settlement for hospital discharges is gaining traction, with major companies like China Life and Ping An reporting direct payments exceeding 4 billion [1][48] - The age groups most affected by medical claims are 30-50 years and 0-17 years, with a higher incidence of claims among males in the child category [1][55][60] Medical Claims Overview - Medical claims have shown rapid growth, with total payouts reaching 405.2 billion in 2024, a sevenfold increase compared to ten years ago [12][87] - The report includes data from 68 life insurance companies, with 60 companies disclosing medical claims totaling over 86 billion [12][13] - Major insurers like Renmin Health reported over 20 billion in claims, while Ping An Life and Ping An Health reported over 12 billion [13][14] Claim Characteristics - The medical insurance claims are characterized by high frequency and low average payout, with nearly 80% of companies reporting average claims below 3,000 [19][34] - The report emphasizes that while average payouts may seem low, the high frequency of claims reflects the nature of medical insurance as a reimbursement product [19][20] High Payout Cases - Notable cases include individuals receiving over 3 million in claims, with companies like Fude Life, Xinhua Insurance, and AIA reporting multiple high-claim cases [26][30] - The report details that some medical insurance products have guaranteed renewal periods, allowing for cumulative payouts to exceed initial coverage limits [26] Special Drug Payments - In 2024, Ping An Health paid over 19 billion for special drugs, while Taibao Health reported a maximum payout of 1.2 million for CAR-T therapy [36][44] - The introduction of commercial health insurance innovation drug directories in the 2025 medical insurance catalog is expected to enhance coverage for previously excluded innovative drugs [40][41] One-Stop Settlement - The trend of one-stop settlement for medical claims is being adopted by several insurers, with 11 companies reporting direct payment amounts exceeding 12 billion in 2024 [50][51] - Companies like China Life and Ping An Life have reported direct payments exceeding 4 billion, indicating a shift towards more efficient claim processing [51][49] Age and Gender Distribution - The report indicates that the most common age groups for medical claims are 30-50 years and 0-17 years, with a notable prevalence of claims among males in the child category [55][60] - Female claims are generally higher in adult age groups, reflecting greater health awareness and insurance purchasing behavior among women [62][66] Claim Causes - The majority of medical claims are due to diseases, with respiratory infections being the most common reason for claims [72][76] - In contrast, accidental claims are primarily related to animal bites and sprains, highlighting the different nature of claims in medical insurance [81][82]

Core Viewpoint - The article discusses the introduction of a "Commercial Insurance Innovative Drug Directory" as part of the 2025 medical insurance directory adjustment, marking the beginning of a dual-directory era for medical insurance and commercial health insurance in China [1][10][11]. Group 1: Introduction of the Dual-Directory System - The 2025 medical insurance directory will for the first time include a "Commercial Insurance Innovative Drug Directory," allowing innovative drugs that are not covered by medical insurance to be reimbursed by commercial insurance [2][10]. - This adjustment aims to clarify the boundaries of basic medical insurance coverage and enhance the collaboration between commercial health insurance and basic medical insurance [21][24]. Group 2: Features of the Commercial Insurance Innovative Drug Directory - The "Commercial Insurance Innovative Drug Directory" will focus on innovative drugs that have high innovation levels, significant clinical value, and substantial patient benefits, which exceed the coverage of basic medical insurance [24]. - The directory will allow companies to apply for inclusion in either the medical insurance directory or the commercial insurance directory, or both simultaneously [27][28]. Group 3: Payment and Collaboration Mechanisms - The article highlights the importance of synchronizing settlements and data collaboration between medical insurance and commercial health insurance, facilitating a smoother reimbursement process for patients [4][39]. - The introduction of the "three exclusions" support for the commercial insurance innovative drug directory will ensure that these drugs are not subject to certain basic medical insurance metrics, allowing for more flexible pricing negotiations [31][32]. Group 4: Growth of Commercial Health Insurance - Since 2014, the commercial health insurance sector has experienced rapid growth, with premium income reaching 97.73 billion by the end of 2024, more than six times the amount from a decade ago, reflecting a compound annual growth rate of approximately 20% [41]. - The article notes that the claims for medical insurance have also seen significant increases, with medical claims accounting for 44% and critical illness claims for 36% of total payouts in 2024 [43].

Core Viewpoint - The seminar emphasized the importance of commercial health insurance in supporting China's modernization process, addressing supply-demand imbalances, and proposing strategies for innovation and service upgrades in the industry [2][4]. Group 1: Product Innovation - The health insurance industry faces a supply-demand mismatch, with issues such as premium exceeding coverage for critical illness insurance and stagnant growth in medical insurance [4][6]. - To address these challenges, the company is exploring product innovation focused on three areas: deep integration of health management with insurance products, development of differentiated medical insurance, and reform of group medical products [4][6]. - A new product, "Rui Xing Bao," aims to reduce risks for insurance companies while providing access to coverage for clients with pre-existing conditions through a model centered on prevention and immediate management [5][6]. Group 2: Service Upgrade - Service upgrades are crucial for the development of commercial health insurance, with a focus on creating a comprehensive service system that covers the entire disease management process [6][8]. - The company aims to enhance service offerings by providing health management during the prevention phase and comprehensive support during treatment and recovery [6][8]. - Key areas for deepening service include improving high-frequency services like green channel access for critical illnesses and increasing awareness of disease prevention [8][9]. Group 3: Ecological Collaboration - The company advocates for the integration of internal and external resources to create a closed-loop health insurance ecosystem [7][9]. - By leveraging open medical insurance data, the company seeks to enhance risk assessment and pricing through intelligent underwriting and refined cost control [7][8]. - The focus is on developing a dual-track design for medical insurance that caters to both basic and high-end medical needs, ensuring broader access to essential healthcare [7][8].

2025年6月6日，第二届"保险家论道"研讨会暨中国保险竞争力排行榜发布会在北京成功举 办。本次研讨会由清华大学五道口金融学院《清华金融评论》编辑部主办，会议主题 为："保险服务中国式现代化"。会议上，多位来自国内保险领域的顶尖学者和资深从业 者，围绕保险行业如何做好五篇大文章，推动经济高质量发展等话题进行交流探讨。现场 座无虚席，受到社会各界人士的广泛关注。明 亚保险经纪营销中心助理总监刘存鑫围 绕"商业健康险的破局与未来"主题展开深度对话。 刘存鑫表示，医保体制改革正在重塑商业健康险的价值边界，对行业既是挑战也是机会。改 革后医院与医生对商保身份识别弱化，客户权益无法保障，导致销售端遭遇困境。他认为， 保险公司应积极转向中高端医疗市场，针对不同客户群体精细化设计产品，同时强化服务的 主动性与穿透力，基于理赔与健康管理数据，实现前置干预与客户全周期陪伴。此外，商保 发展不能脱离医保，应推动身份识别、资源对接与系统协同，共建更有温度、也更高效的健 康保障生态。 图为 刘存鑫 分享 以下为嘉宾演讲全文 产品边界的重塑与服务的再定位 在当下环境下，我们不能再用过去"百万医疗"一类大而全的思路来满足中高净值客户的 ...