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Occupational Accident Workers May Claim Medical Care Benefits of LOAI If He/She Suffers from a Fracture Due to Traffic Accident and Opt for the “Special Materials Requiring Partial Out-of-Pocket Payments” for the Surgery.

In order to improve the medical care benefits rights of the occupational accident workers and reduce their financial burden against the medical services, the government has, since the implementation of the Labor Occupational Accident Insurance and Protection Act on May 1, 2022, incorporated the “NHI Special Materials Requiring Partial Out-of-Pocket Payments” into the benefit coverage of LOAI, in addition to the “NHI Special Material Fully Covered by the Insurer” which has already been covered by the LOAI.

To explain, the BLI provided an example. Mr. Wei was employed by a company and suffered from a left femur fracture caused by a traffic accident on his way to the office. Based on the evaluation of the physician, Mr. Wei needed a long intramedullary nail system (18cm or longer) to achieve adequate fixation, considering the length of the fracture. The system, however, was categorized as a “NHI Special Material Requiring Partial Out-of-Pocket Payments”. The NHI covered NTD19,000 or so, and Mr. Wei needed to pay more than NTD60,000 out-of-pocket. Mr. Wei selected the above special material and paid partial out-of-pocket payments upfront. He claimed reimbursement from the BLI afterwards. The case was reviewed by the BLI and Mr. Wei received the reimbursement of more than NTD60,000 as a coverage from the LOAI medical care benefits.

According to the BLI, there are three types of special material at present, respectively, “NHI Special Material Fully Covered by the Insurer”, “NHI Special Material Requiring Partial Out-of-Pocket Payments” and “NHI Special Material Requiring Out-of-Pocket Payment in Full by the Insured”. Of the three types, the first two are covered by the LOAI medical care benefits. Therefore, when a worker suffers from an occupational injury or illness (or any disease caused thereby) and, according to the opinions of a physician of a NHI-contracted medical institution, needs to opt for special material requiring partial out-of-pocket payments, he/she may file a claim to the BLI for reimbursement of such upfront payment, presenting the “Labor Occupational Accident Insurance - Application for Reimbursement of the Out-of-pocket Payment of Medical Expenses”, payment receipt of the medical expenses, diagnosis statement and the letter of consent for the out-of-pocket payment.

The BLI further explained that, when reviewing the application documents, there were often cases where the “Consent form For Partial Out-of-pocket Payments” was missing. In some cases, the applicant has, due to misunderstanding, filed a claim against the special material which required out-of-pocket payment in full by the insured. The BLI, therefore, reminded the applicants to attach the consent along with other application documents to reduce documentation burden.

For more details about the qualification, payment standards and application procedures of occupational accident medical care benefits and reimbursement of the payments for the special material, please refer to An Introduction to the Labor Occupational Accident Insurance Medical Care Benefits and the relevant explanation in the application form.
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Last Update:2024-05-06