2025.11. 23 本文字数：2389，阅读时长大约4分钟 作者 | 第一财经 吴斯旻 在老龄化加速、基本医保基金持续承压的背景下，商业健康险发展始终伴随争议。争议背后是，商业 健康险被公众质疑为赔付总额低、与保费规模的增长节奏不匹配。 国家金融监管总局数据显示，2024年，中国商业健康险保费收入合计达到9774亿元，同比增长 8.2％，增速较去年同期提升3.8个百分点。2025年前8个月，商业健康险保费收入突破7599亿元， 有业内人士预测今年全年商业健康险保费规模有望突破万亿元大关。 而从赔付情况来看，2024年，商业健康险赔付支出约4037.77亿元。如果使用简单赔付率(当年赔付 支出与当年保费收入之比)单一指标进行评估，不难得出中国商业健康险赔付率在40％左右的结论， 而这显著低于发达国家水平(70%～85%)。 但在商保业界人士看来，这样的测算有失偏颇，甚至与实际情况相去甚远，无法真实反映中国商业健 康险的保障效能与盈利状况。 这是因为疾病保险(以重疾险为主)与医疗保险作为商业健康险的主要险种，贡献了超过95％的保费规 模，但其中占据约50％保费规模的重疾险，并非实报实销类保险，它的保障期长，存 ...

根据研究，长期医疗险的赔付率稳定在55%～80%，短期健康险中个人业务实际综合赔付率达50%～ 70%，团体业务赔付率位于100%～120%区间。 在老龄化加速、基本医保基金持续承压的背景下，商业健康险发展始终伴随争议。争议背后是，商业健 康险被公众质疑为赔付总额低、与保费规模的增长节奏不匹配。 国家金融监管总局数据显示，2024年，中国商业健康险保费收入合计达到9774亿元，同比增长8.2％， 增速较去年同期提升3.8个百分点。2025年前8个月，商业健康险保费收入突破7599亿元，有业内人士预 测今年全年商业健康险保费规模有望突破万亿元大关。 而从赔付情况来看，2024年，商业健康险赔付支出约4037.77亿元。如果使用简单赔付率(当年赔付支出 与当年保费收入之比)单一指标进行评估，不难得出中国商业健康险赔付率在40％左右的结论，而这显 著低于发达国家水平(70%～85%)。 但在商保业界人士看来，这样的测算有失偏颇，甚至与实际情况相去甚远，无法真实反映中国商业健康 险的保障效能与盈利状况。 这是因为疾病保险(以重疾险为主)与医疗保险作为商业健康险的主要险种，贡献了超过95％的保费规 模，但其中占据约50 ...

Core Insights - The industry has not reached a consensus on the relationship between negotiated discount prices and claims for innovative drugs under commercial insurance [1][2] - The first version of the commercial insurance innovative drug directory is set to be released on the first weekend of December and will be implemented starting January 1 of next year [1] - A total of 121 drugs have been reviewed through the commercial insurance innovative drug directory this year, with around 80 drugs applying for both the basic medical insurance directory and the commercial insurance innovative drug directory [1] Group 1: Expectations and Challenges - Different stakeholders have varying expectations from the commercial insurance innovative drug directory; pharmaceutical companies hope to expand coverage through discount commitments, while commercial health insurance companies aim to manage high-cost drug reimbursement risks [1][2] - Two main challenges identified include clarifying the relationship between negotiated prices and claims responsibilities, and establishing a clear mechanism for pharmaceutical companies to return discounts to insurers [2][5] Group 2: Pricing Mechanisms - The introduction of the commercial insurance innovative drug directory aims to enhance the payment capabilities for innovative drugs and strengthen the associated policy framework [3] - The National Healthcare Security Administration (NHSA) proposes a mechanism for price confidentiality, allowing pharmaceutical companies to negotiate discounts with insurers while keeping the negotiated prices confidential [3][4] Group 3: Implementation and Operational Challenges - The successful implementation of the directory requires addressing challenges related to the existing actuarial models of commercial insurance products and compliance with industry regulations [7][8] - The path for returning discounts from pharmaceutical companies to insurers remains unclear, with the NHSA requiring the industry to explore solutions within three months of the directory's launch [9][10] Group 4: Opportunities and Market Dynamics - The directory's introduction provides an opportunity for insurers to engage directly with pharmaceutical companies, enhancing negotiation capabilities [14] - The complexity of discount return mechanisms and price confidentiality may still involve intermediaries, indicating potential challenges in the practical application of these agreements [14]

Core Insights - The insurance industry is actively participating in the "Double 11" shopping festival, utilizing diverse marketing strategies to attract consumers [1][2] - Major insurance companies are offering discounts, giveaways, and promotional guides to encourage insurance purchases during this shopping event [2][3] - The trend of significant discounts on insurance products has decreased due to stricter regulations and a shift towards rationality in the industry [4] Marketing Strategies - Insurance companies are employing various promotional tactics, including direct premium discounts, lottery draws, and shopping card giveaways [2][3] - The marketing campaigns are designed to integrate insurance into the shopping experience, making it more appealing to consumers [2][3] - Some companies are focusing on health insurance products, offering discounts on critical illness and children's medical insurance to address consumer concerns about health risks [2][3] Regulatory Environment - The insurance sector is facing stricter regulations that discourage unreasonable price competition and emphasize the core function of insurance as protection rather than a promotional commodity [4] - Companies are recognizing that relying solely on price competition is unsustainable, especially for long-term life insurance products [4] Consumer Considerations - Consumers are advised to focus on the core value of insurance, which is protection, rather than just the price [6][7] - It is essential for consumers to compare key terms such as coverage, exclusions, and renewal conditions when selecting insurance products during promotional periods [6][7] - The "Double 11" promotions can serve as an opportunity for consumers to learn about and purchase insurance, but they should prioritize their needs and carefully evaluate the terms of the products [7]

Core Insights - The insurance industry is actively participating in the upcoming "Double 11" shopping festival, employing diverse marketing strategies to attract consumers [3][4] - Insurers are offering various promotional activities, including premium discounts, giveaways, and educational content to encourage insurance purchases during the shopping frenzy [4][5] - The trend of significant discounts on insurance products has diminished due to stricter regulations and a shift towards rationality in the industry [6][7] Group 1: Marketing Strategies - Insurers are utilizing a range of promotional tactics, such as direct premium discounts, lottery draws, and shopping card giveaways, to engage consumers [4][5] - The marketing approach has become more scenario-based and entertaining, combining insurance education with incentives for consumers [5] - Major insurance companies like China Life, New China Life, and Ping An Property & Casualty are launching targeted campaigns for "Double 11" [4] Group 2: Regulatory Environment - The decline in substantial insurance discounts is attributed to increased regulatory scrutiny and a focus on the core function of insurance as protection rather than a promotional commodity [6][7] - Regulatory bodies have emphasized the importance of avoiding unreasonable low-price competition, leading insurers to seek sustainable strategies beyond price wars [7] Group 3: Consumer Considerations - Consumers can benefit from lower costs during promotional periods, but should prioritize coverage quality over price alone [8][9] - Key factors for consumers to consider include coverage scope, exclusions, premium amounts, and the insurer's service capabilities [9] - The types of discounted insurance products mainly include travel accident insurance, medical insurance, and home insurance, which typically have shorter terms and simpler clauses [9]

Core Insights - The article highlights a successful intervention by the Urumqi branch of Industrial Bank to prevent a telecom fraud targeting elderly clients, specifically protecting a client’s funds amounting to 1.44 million yuan [1][2]. Group 1: Fraud Prevention Measures - The fraud scheme involved a phone call claiming that the client's "million medical insurance" had an "automatic deduction anomaly," which preyed on the elderly's concern for medical security [1]. - The bank's intelligent risk control system detected unusual transaction patterns, such as "early withdrawal of fixed deposits" and "frequent access to unknown links," triggering a risk alert that was communicated to the dedicated account manager [1][2]. - The account manager promptly contacted the client to verify the transaction, identifying the potential fraud when the client was unclear about the operation details and the source of the link [1][2]. Group 2: Client Education and Support - The bank emphasized that legitimate financial institutions would never request clients to withdraw funds via unknown links, and the account manager assisted the client in verifying account status, successfully preventing any fund transfer [2]. - The bank has been enhancing its risk prevention measures, focusing on monitoring suspicious activities among elderly clients, such as "large transfers to unknown accounts" and "frequent clicks on unknown links" [2]. - The bank conducts regular community outreach programs to educate elderly individuals on recognizing fraud tactics and protecting their account information [2][3]. Group 3: Awareness and Caution - The Urumqi branch of Industrial Bank advises elderly clients and their families to be vigilant against common fraud scenarios, such as "medical deduction anomalies" and "urgent money requests from relatives," and to verify any suspicious calls or links with bank representatives or family members [3].

Core Insights - The commercial health insurance sector is at a transformative crossroads, driven by the integration of insurance payments with innovative drugs and health management services, referred to as the "insurance + medicine" ecosystem [1][6] Policy and Market Dynamics - The Chinese innovative drug industry is experiencing rapid growth, with 43 innovative drugs approved in the first half of 2025, a 59% increase year-on-year, while the sales revenue for innovative drugs reached 162 billion yuan in 2024 [2] - The payment structure for innovative drugs is imbalanced, with personal cash payments at 49%, insurance fund payments at 44%, and commercial health insurance covering only 7.7% [2] - New policies, such as the establishment of a commercial health insurance innovative drug directory, are aimed at integrating commercial health insurance into the multi-channel payment system for innovative drugs [2][3] Market Challenges and Opportunities - The health insurance sector is under pressure, with a mere 2.3% growth in original insurance premium income in the first half of 2025, below the industry average [4] - The aging population, with 15.6% of the population aged 65 and above in 2024, is increasing the urgency for transformation in health insurance [4] - The market for innovative drug payments is expanding, with 441 innovative drugs included in commercial insurance since 2019, indicating a growing trend towards differentiated competition among insurance companies [5] Ecosystem Development - The "insurance + medicine" ecosystem is emerging, where insurance companies collaborate with pharmaceutical firms and healthcare platforms to enhance service offerings and risk management [6] - Companies are innovating products to include coverage for innovative drugs, with examples like the "TaiKang Million Drug Worry-Free" insurance policy that covers a wide range of medications [6] Service Integration and Challenges - There is a call for integrating service responsibilities into insurance policies to enhance customer experience and risk management efficiency [7] - Data silos between medical institutions, pharmaceutical companies, and insurance firms pose significant challenges to the effective implementation of innovative drug coverage [8] - Ensuring the quality of medical services related to innovative drug payments is critical, with leading insurance companies beginning to build or partner to create comprehensive medical service networks [8] Future Outlook - Companies that successfully build a closed-loop capability in the medical insurance ecosystem are likely to establish a competitive advantage [9] - The commercial health insurance sector is shifting from a price competition model to one focused on service and ecosystem development, indicating a new battleground for innovative drug payments [9]

Core Viewpoint - China Life Insurance Company has demonstrated strong claims service capabilities, with over 44 million claims and more than 73 billion yuan in payouts in the first three quarters of 2025, maintaining a leading position in the industry [2][4]. Claims Performance - In the first three quarters of 2025, China Life processed a total of 44.09 million claims, amounting to 73.3 billion yuan in payouts [4]. - Health insurance claims accounted for over 43.4 million cases, reflecting a year-on-year increase of over 13.3%, with payouts exceeding 56 billion yuan, a year-on-year increase of over 2.2% [4]. - The distribution of claims across four major categories was as follows: 19.1% for death, 58.0% for medical, 18.3% for critical illness, and 3.0% for disability [4]. Technological Innovations - China Life is actively responding to the "Digital China" strategy by exploring cutting-edge insurance fields and transforming claims services to enhance efficiency [6]. - The company has integrated systems with social security, medical institutions, and third-party data companies to simplify claims processes, achieving 5.98 million direct payment claims totaling over 3.2 billion yuan in the first three quarters of 2025 [6]. - The introduction of the "electronic invoice hassle-free claims" service resulted in 6.93 million claims processed with an average service time of only 0.28 days [6]. Health Trends and Recommendations - Claims data reflect changing trends in customer risk exposure, with an increase in cardiovascular disease claims during the autumn and winter seasons compared to spring and summer [8]. - The company emphasizes the importance of preventive measures against high-incidence diseases and suggests timely medical insurance product configurations to enhance health protection [8]. - There is a noted gap in critical illness insurance coverage, particularly for malignant tumors, which account for over 70% of critical illness claims, yet the average payout is only 43,000 yuan, highlighting the need for supplementary commercial health insurance [8]. Commitment to Service - China Life continues to fulfill its role as an economic "shock absorber" and social "stabilizer," providing prompt and compassionate claims services to its customers [9].

Core Insights - China Life Insurance Company reported over 44 million claims and more than 73 billion yuan in payouts for the first three quarters of 2025, maintaining a leading position in the industry [1][2] Claims Performance - The total number of claims for the first three quarters of 2025 reached 44.09 million, with total payouts amounting to 73.3 billion yuan [2] - Health insurance claims accounted for over 43.4 million cases, reflecting a year-on-year increase of over 13.3%, with payouts exceeding 56 billion yuan, a year-on-year increase of over 2.2% [2] - The distribution of claims across four major categories was as follows: 19.1% for death, 58.0% for medical, 18.3% for critical illness, and 3.0% for disability [2] Technological Innovations - The company is actively exploring the frontiers of insurance by integrating technology into claims services, aligning with the "Digital China" strategy [3] - In the first three quarters of 2025, China Life processed 5.98 million direct payment claims, totaling over 3.2 billion yuan [3] - The introduction of the "electronic invoice hassle-free claim" service resulted in 6.93 million claims processed with an average service time of only 0.28 days [3] Health Risk Insights - The company highlighted the increased risk of cardiovascular diseases during the autumn and winter seasons, with claims data indicating a 5% rise in such cases compared to spring and summer [4] - Recommendations were made for preventive measures against high-incidence diseases, particularly for minors in enclosed school environments [4] Critical Illness Insurance Gaps - Data revealed that malignant tumors accounted for over 70% of critical illness claims, yet the average payout of 43,000 yuan is significantly lower than treatment costs [4] - The need for commercial health insurance to supplement basic medical coverage for innovative and expensive treatments was emphasized [4] Commitment to Service - China Life Insurance positions itself as a stabilizing force in the economy, providing timely and compassionate claims services to its clients [5]

Group 1 - The core viewpoint of the news is that China Life Insurance Company has demonstrated strong performance in claims processing for the first three quarters of 2025, with over 44 million claims and a total payout exceeding 73 billion yuan, maintaining a leading position in the industry [1] Group 2 - In the first three quarters of 2025, China Life processed a total of 44.09 million claims, with a payout amount of 73.3 billion yuan. Health insurance claims accounted for over 43.4 million, reflecting a year-on-year increase of over 13.3% in claim numbers and over 2.2% in claim amounts [1] - The distribution of claims by category includes 19.1% for death, 58.0% for medical, 18.3% for critical illness, and 3.0% for disability [1] Group 3 - China Life has focused on integrating "medical + insurance + internet" services, simplifying claims procedures through collaboration with social security, medical institutions, and third-party data companies, allowing for proactive claims support [1] - The company provided direct payment services for 5.98 million claims, with a payout exceeding 3.2 billion yuan in the first three quarters of 2025 [1] - An innovative "electronic invoice hassle-free claim" service was launched, processing 6.93 million claims with an average service time of only 0.28 days [1] Group 4 - The report highlights that there are still shortcomings in critical illness insurance coverage, particularly for malignant tumors, which account for over 70% of critical illness claims. The average payout for malignant tumors is only 43,000 yuan, which is significantly lower than the treatment costs [2] - The need for commercial health insurance as a supplementary payment method is emphasized, especially for innovative drugs that are not fully covered by basic medical insurance [2] - It is recommended to allocate medical insurance products that cover out-of-pocket expenses for advanced treatment options within budget constraints to enhance overall medical coverage [2]