The Supreme People's Court issued a judicial interpretation to unify the applicable standards for advance payments from medical insurance funds.
Third-party liability denied in case of accident? Medical insurance can make advance payment.
(Reporter Lu Yue) On January 6, the Supreme People's Court issued the "Reply of the Supreme People's Court on Issues Concerning the Application of Law Regarding the Application Conditions for Advance Payments from Basic Medical Insurance Funds" (hereinafter referred to as the "Reply"), further clarifying the statutory application conditions for advance payments from basic medical insurance funds and unifying the standards for the application of law. The "Reply" will take effect on February 1, 2026.
The "Reply" clarifies that, according to Article 30 of the "Social Insurance Law of the People's Republic of China" and Articles 2 and 3 of the "Interim Measures for Advance Payment by Social Insurance Funds," if an individual participating in basic medical insurance (hereinafter referred to as the insured) suffers injury or illness due to the tortious act of a third party, and the medical expenses that should legally be borne by the third party are not paid by the third party or cannot be identified, the basic medical insurance fund shall make advance payments. When the insured applies in writing to the social insurance agency in their place of insurance for advance payment, they should inform the agency of the cause of their injury or illness and the circumstances of the third party's non-payment of medical expenses or the inability to identify the third party. After reviewing the application in accordance with the law, the social insurance agency shall make advance payments for the corresponding portion of the medical expenses in accordance with the regulations on advance payment by the basic medical insurance fund in the unified planning area.
It is reported that because the Social Insurance Law does not provide further specific regulations on advance payment and reimbursement of medical expenses, local social security administrative departments, in practice, handle related matters according to the "Interim Measures for Advance Payment of Social Insurance Funds" and local operating procedures. This leads to a generally stricter interpretation of the conditions for advance payment and reimbursement in business operations, resulting in the frequent delays or refusal of payment for insured individuals' medical expenses. Insured individuals are significantly disadvantaged when a third party is involved compared to when no third party is involved. How to correctly determine the application conditions for advance payment from the basic medical insurance fund, especially whether advance payment from the basic medical insurance fund requires that the insured individual has not paid medical expenses themselves "at the time of medical expense settlement," is subject to differing interpretations of relevant laws and regulations in practice.
In response, the "Reply" states that the insured person's right to apply for advance payment from the basic medical insurance fund is not affected by whether or not they have already paid for the medical expenses at the time of settlement. If the social insurance agency refuses to make advance payment solely on the grounds that the insured person has already paid for the medical expenses at the time of settlement, and the insured person files a lawsuit requesting the social insurance agency to make advance payment, the people's court shall support such a lawsuit in accordance with the law.
The "Reply" further clarifies the right of social insurance agencies to seek reimbursement after making advance payments in accordance with the law. It stipulates that social insurance agencies may seek reimbursement for medical expenses paid in advance in accordance with Articles 11 and 12 of the "Interim Measures for Advance Payment of Social Insurance Funds." (Workers' Daily)
