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(釋字第 389 號 )
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Interpretation
J.Y. Interpretation |
NO.389
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Date |
1995/11/10 |
Issue |
Is it unconstitutional to exclude hereditary chronic disease or a deformity that occurred/existed before a worker enrolled in the labor insurance program from labor insurance coverage? |
Holding |
1 According to Article 44 of the Labor Insurance Act, cosmetic surgery is excluded from medical indemnity. In addition, Article 19, Paragraph 1, of the same Act stipulates that in the case where an insurance peril happens after an insurance policy takes effect and before such policy is terminated, the insured or his/her beneficiary shall be entitled to claim insurance benefit payments. The Standard Forms for Payment of Labor Insurance Medical Coverage are made under authorization of Article 51, Paragraph 2, of the Labor Insurance Act. In connection with corrective surgery for the jaw, Part 9, Section 4, Paragraph 2, of the Standard Forms specifies, in accordance with Article 51, Paragraph 2, of the same Act, that a claim of medical care benefits is "restricted to special cases, with approved application, of external injuries or painful jaw joints" on the grounds that such cases satisfy the prerequisite that accidents may happen after an insurance policy takes effect and before such policy is terminated, and that the subject medical treatment is not cosmetic surgery. Hereditary chronic disease or a deformity that occurred/existed before a worker enrolled in the labor insurance program is not covered; hence, there will be no medical care benefits. This is within the authorized scope of the said Act and does not contradict the Constitution.
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Reasoning |
1 According to Article 19, Paragraph 1, of the Labor Insurance Act, in the event where an insurance peril happens after an insurance policy takes effect and before such policy is terminated, the insured or his/her beneficiary shall be entitled to claim insurance benefit payments. It is therefore stipulated that claim of insurance benefit payments is restricted to insurance perils which happen after an insurance policy takes effect and before such policy is terminated. In addition, since labor insurance belongs to social insurance and for the purpose of avoiding waste of medical resources, Article 44 of the Labor Insurance Act stipulates: "Medical care benefits shall not be paid for legally declared epidemics, leprosy, narcotic addictions, child delivery, miscarriage, plastic surgery, false teeth, prosthetic eyes, eyeglasses or accessories, patient transportation, special nurses, blood transfusion, registration fees, charges for documents, treatments for which facilities are not available at the hospital or clinic, or other items which are not referred to in Articles 41 or 43, except in the case of blood transfusion in an emergency treatment of an insured person deemed by the hospital operated or specially contracted by the insurer to be strictly necessary." Obviously, cosmetic surgery is outside the scope of "injury or illness suffered by the insured" as provided for in Article 40 of the Labor Insurance Act, and is not eligible for medical care benefits. Laws and regulations, however, cannot stipulate all the details; therefore, the legislative branch may authorize the competent authority to promulgate supplementary provisions for technical matters and details regarding medical treatment. Hence the stipulation in Article 51, Paragraph 1, in the same Act: "Payment shall comply with the Standard Forms for Payment of Labor Insurance Medical Coverage, and the Standard Forms for Acceptable Medicines List and Their Prices." The central Competent authority is authorized in accordance with Paragraph 2 of the same Article to prescribe the aforesaid Standard Forms for Payment of Labor Insurance Medical Coverage, and the Standard Forms for Acceptable Medicines List and Their Prices upon consultation with the central competent authority in charge of health matters. In connection with corrective surgery for the jaw, Part 9, Section 4, Paragraph 2, of the said Standard Forms specifies, in accordance with Article 51, Paragraph 2, of the same Act, that claim of medical care benefits is "restricted to special cases, with approved application, of external injuries or painful jaw joints" since such cases satisfy the prerequisite that an accident may happen after an insurance policy takes effect and before its termination, and that the subject medical treatment is not cosmetic surgery. Hereditary chronic disease or a deformity that occurred/existed before a worker enrolled in the labor insurance program is not covered; hence, there will be no medical care benefits. This is within the authorized scope of the said Act and does not conflict with the Constitution. 'Translated by Dr. C.Y. Huang of Tsar & Tsai Law Firm.
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Opinion |
Chinese only
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