Policy's STD exclusion does not cover AIDS discrimination

A Federal judge in Philadelphia ordered General Star Indemnity Company to pay litigation and settlement expenses incurred by the 12th Street Gym. General Star maintained that the insurance policy sold to the gym excluded all claims arising from sexually transmitted diseases. The gym had to defend itself in a civil lawsuit brought by a client who claimed he was ejected because he had AIDS. When General Star refused to pay to defend the suit or cover judgement, 12th Street Gym sought a declaratory judgement in U.S. District Court to resolve the dispute. After the patron died, his estate reached a settlement with the gym, and while General Star Indemnity agreed to pay defense costs for litigation and advanced the gym the cash for the settlement, it reserved the right to seek repayment once the declaratory judgment was made. In June 1995 a U.S. district judge found in favor of the gym but the 3rd U.S. Circuit Court of Appeals remanded the case for an evidentiary hearing. The judge then determined that the wording of the policy was ambiguous and ruled that the plausible interpretation of the policy would prevail, thereby ordering the insurance company to reimburse the gym for the cost of defending and settling this lawsuit.     

进一步完善医疗保险政策

在进行职工基本医疗保险制度改革和进一步完善医疗保险政策的过程中，要注意四个问题；属地原则和“条”、“块”矛盾问题；关于“社会统筹”与“个人帐户”结合；关于“基本”与“补充”的关系；关于特困人群的医疗保障。     

社会医疗保险的政策选择与政策偏好

社会医疗保险政策选择是医疗保险体系的重要组成部分,与体系中的行为主体存在紧密联系和关联,影响着整个体系的效率(效益),发挥着不可替代的作用,构成事实上的一种机制。医疗保险政策选择主体偏好显示的制度供给存在短缺。     

灵活就业人员医疗保障政策难点分析

灵活就业人员规模日益扩大,其社会保障问题,尤其是医疗保险问题日益突出。目前灵活就业人员医疗保险正在各地展开,并取得一定的成效,但也存在一些问题。正视并解决这些问题是医疗保险制度改革继续深化的重要保证。     

Spillover effect of Japanese long-term care insurance as an employment promotion policy for family caregivers

We evaluate a spillover effect of the Japanese public long-term care insurance (LTCI) as a policy to stimulate family caregivers’ labor force participation. Using nationally representative data from 1995 to 2013, we apply difference-in-difference propensity score matching to investigate the spillover effect in two periods: before and after the introduction of the LTCI in 2000 and before and after its major amendment in 2006. Our results show that the LTCI introduction has significant and positive spillover effects on family caregivers’ labor force participation and the effects vary by gender and age. In contrast, the LTCI amendment is found to have generally negative spillover effects on their labor force participation. We draw attention to these spillover effects, as expanding labor market supply to sustain the economy would be a priority for Japan and other rapidly aging countries in the coming decades.     

Using social health insurance to meet policy goals

Social health insurance, with contributions based on incomes and access to services on need is being considered as an option for health care finance in many countries. The argument in this paper starts from the premise that the choice of health care financing mechanisms should start with a clear focus on policy goals, with different options judged against the extent to which these are met. These are likely to include objectives of access to care for those in need, quality of care, incentives for efficient provision and cost control. Different systems will meet the objectives of mobilising resources, providing insurance against risk and redistribution resources to differing extents. It is argued that a particular problem in health care finance is shifting rights to resources over time. It is also important to be clear about the distinction between affordability of and payment mechanisms for health care. The choice of funding mechanisms may have little effect on other policy goals, such as economic development. However, they may differ in the degree to which they allow specific health policy goals to be met. Different mechanisms for collecting and managing funds, and for paying for services are discussed. The paper concludes with concerns that too much emphasis is placed on structures and not how they work, that a lack of cost control may be a serious risk in developing social health insurance and that it is important to have clear mechanisms for setting priorities if policy goals are to be met.     

Integration, exclusion and solidarity in the current social policy debate

The current global trend involving transformation of work and the crisis in large government economic development and intervention projects in the market are raising new challenges for social policies to combat poverty. This study reconstitutes and analyzes the tensions, paradoxes, and main consequences of this process, focusing on problems concerned with combining solidarity strategies and public welfare systems.     

德国LTCI及其改革

介绍了德国的护理保险制度,探讨了该制度对我国面临人口老龄化医疗保险政策制定的启示。     

上海市商业健康保险制度研究

通过对国际医疗保健模式的比较和国内社会医疗保险及商业健康保险的分析,并结合高端医疗服务的现状,提出建立适应上海高端人群医疗服务特点的上海商业健康保险新模式。基本医疗服务由社会保险给予支付,高端医疗服务通过分类给付办法,即在社会医疗保险支付基本医疗服务费用基础上,其余费用由商业健康保险给予支付。基本医疗保险与商业健康保险相结合,满足不同层次人群对医疗服务的需求。     

Tax policy and the demand for health insurance

Estimates of the price and income elasticities of demand for health insurance are derived from econometric estimates of the parameters of a discrete choice model of health insurance demand using data from a survey of plan choices among a sample of federal government employees. The estimated income elasticity (+0.01) is similar to most previous estimates. The estimated price elasticity (-0.16) is in absolute value much less than the earlier previous estimates and somewhat less than the more recent previous estimates. Possible causes of these differences in price elasticity estimates are discussed.     

Arbitration seen as inappropriate in denial-of-care claim

Dr. Peter G. Mozsary, charged with denying service to a patient with AIDS, has failed in his attempt to change the venue from Federal District Court to an arbitration panel. The California dentist was sued for violating the Americans with Disabilities Act (ADA). Dr. Mozsary argued that the matter involved malpractice and should be settled by arbitration, as stated in an agreement on malpractice claims signed by the patient. But the judge determined that the patient's claim that he was denied care involves civil rights, not malpractice. The plaintiff, known in court records as John Doe, alleged Mozsary refused to treat him upon learning he is HIV-positive, and referred him to a hospital for antibiotic therapy and observation. Dr. Mozsary claims he usually treats people with AIDS, but Doe was suffering from a severe respiratory infection and the nonemergency removal of three decayed teeth could be handled better in a hospital setting. Doe is seeking a jury trial and compensatory and punitive damages.     

Assessment of a school exclusion policy during a chickenpox outbreak

Two Ohio schools experienced an outbreak of over 200 cases of chickenpox during the period from October 5 to December 21, 1988, despite adherence to the 1986 American Academy of Pediatrics' recommendation that children be excluded from school for 1 week or until all lesions have crusted. In grades kindergarten through four, the attack rate for susceptibles was 51% (167/329). With the use of person-time analysis, classmates of a child with chickenpox in grades kindergarten through four were 3.6 times more likely to become a case 12-17 days (the range of one incubation period) after the last day the child with subsequent chickenpox was in class than at any other time during the 2.5-month study period (95% confidence interval (Cl) 2.4-5.4). This was even more pronounced during the first half of the outbreak (relative risk (RR), 10.8; 95% Cl 4.4-26.5). Cases were not more likely to aggregate 12-17 days after a child returned to school after having chickenpox (RR, 0.9; 95% Cl 0.5-1.5). No cases occurred in classmates 12-17 days after the 15 children absent less than 5 days returned to class. Because substantial chickenpox transmission may occur before rash onset, exclusion practices may have a limited effect on outbreak control and increase the indirect costs associated with chickenpox.     

Court upholds voiding of insurance policy based on fraud

A Federal appeals court has determined that an insurer acted properly in refusing to pay life insurance benefits to the survivor of a man with AIDS who fraudulently obtained the insurance. The Eleventh U.S. Circuit Court of Appeals said the late Anthony C. Fioretti fraudulently obtained the policy from Massachusetts General Life Insurance Company in 1986 when he applied for an $1.9 million policy. To qualify for the coverage, Fioretti used an HIV-negative individual to pass an HIV-antibody test. After his death from AIDS-related complications in 1989, the insurance company denied payment of the claim. His brother sued on the basis of an incontestability clause in the policy barring the company from voiding the contract after two years of the effective date. However, the District Court based its decision on the fact that the Supreme Court of New Jersey has ruled an insurer can deny coverage in the case of fraud.