工伤救济先行给付与代位求偿制度探微——兼评《社会保险法》工伤保险基金先行支付制度的得与失

先行给付与代位求偿是保险法上的通例,《社会保险法》第41条、第42条涉及该通例并规定为工伤保险基金先行支付制度。先行支付制度包括垫付性先行支付和保险性先行支付,也称为用人单位未依法缴纳工伤保险费型先行支付和由于第三人的原因造成工伤型先行支付。在社保强制性不足的背景下，     

工伤救济先行给付与代位求偿制度探微——兼评《社会保险法》工伤保险基金先行支付制度的得与失

先行给付与代位求偿是保险法上的通例,《社会保险法》第41条、第42条涉及该通例并规定为工伤保险基金先行支付制度。先行支付制度包括垫付性先行支付和保险性先行支付,也称为用人单位未依法缴纳工伤保险费型先行支付和由于第三人的原因造成工伤型先行支付。     

劳动者的福音:工伤保险待遇先行支付制度

《社会保险法》是保障和改善民生领域的又一部支架性法律,是新中国成立以来第一部社会保险制度的综合性法律。工伤保险待遇先行支付制度是《社会保险法》创设的重要制度,并于2011年7月1日生效实施。《社会保险法》第41条规定:"职工所在用人单位未依法缴纳工伤保险费,发生工伤事故的,由用人单位支付工伤保险待遇。用人单位不支付的,从工伤保险基金中先行支付。从工伤保险基金中先行支付工伤保险待遇     

工伤先行支付“落地”为何这么难

今年是工伤先行支付制度在我国司法实践的第三个年头。2011年7月1日，《社会保险法》生效，其中第四十一条规定：职工所在用人单位未依法缴纳工伤保险费，发生工伤事故的，由用人单位支付工伤保险待遇。用人单位不支付的，从工伤保险基金中先行支付。6月30日，北京义联劳动法援助与研究中心（以下简称“北京义联”）第三次为工伤先行支付制度“落地”呼吁并举行专家研讨会，该中心同时对外发布《工伤保险先行支付制度实施三周年调研报告》。     

用人单位并非工伤保险基金先行支付请求权的权利主体

【要点】1.工伤保险基金先行支付制度的核心价值是为了充分保障工伤职工及时获得医疗救治和经济补偿,故先行支付请求权的权利主体只能是工伤职工或其近亲属,用人单位作为义务主体无权要求先行支付工伤保险待遇。2.在用人单位未参加工伤保险以及虽已参加     

工伤保险先行支付有多难

2012年7月1日，我国《社会保险法》中所确立的工伤保险先行支付制度实施正式满一周年。经历了一年的光阴，这一堪称是工伤劳动者保护史上具有重大突破的制度，在全国范围内的具体实施情况如何？制度执行得顺畅还是“画饼充饥”？这条为工伤劳动者铺就的道路走起来有多艰难？     

浅议先行调解制度

调解在我国有着悠久的历史与文化传统.经过漫长时间的累积,我国公民运用调解来解决纠纷的意识逐渐增强,调解制度也渐渐成为了我国公民解决纠纷的重要方式之一.在新民主主义时期,“马锡五审判方式”就是典型的依靠调解解决纠纷的一种审案方式,该方式重点强调审判与调解需要相互结合,而在民事纠纷过程中则将调解作为主要解决方式.1963年第一次全国民事审判工作会议指出“调查研究、调解为主,就地解决”作为民事审判工作的根本工作方法和工作作风.1982年试行的我国第一部《民事诉讼法》确立了“着重调解”的原则.1991年《民事诉讼法》修改为“自愿、合法调解”原则.2002年、2004年最高人民法院接连颁布两条规定,进一步加强了关于审理民事案件中调解制度的使用原则和具体办法,为后来调解制度正式确立奠定基础.2012年《民事诉讼法》第122条第一次在立法上确立了先行调解制度.目前,先行调解制度尽管有了立法上的支持,但新修订的民诉法第122条对先行调解制度规定的较为原则,本文对“先行调解,”的内涵、适用条件和适用规则提出自己的观点,建议进一步予以完善.     

先行处理程序与正义

借鉴国外经验建立起来的行政先行处理程序制度,作为行政赔偿制度的核心,现在却成为阻碍行政赔偿制度发展的枷锁。那么这个制度是否正义本文运用罗尔斯的两个正义原则,从实质正义和形式正义两方面来研究先行处理程序的正义,分析该制度正义与否,以此奠定先行处理程序存在的正义基础,对今后先行处理程序的发展和完善指引方向。     

浅析我国先行处理赔偿程序

先行处理程序虽然是国家赔偿法中一细小制度,但它的影响却是不能忽略,目前我国的先行处理制度还显有不足,本文简单介绍先行处理的内容,然后阐述该制度存在的缺陷,并提出了完善之法。     

工伤保险基金先行支付的基金安全探析

2010年《中华人民共和国社会保险法》确立了工伤保险基金先行支付制度,具有开创性的意义。然而,工伤保险基金所面临的压力也越来越大,基金安全成为影响该制度有效运行的最大挑战。本文从资金基础、支付渠道和待遇标准两个方面论述了工伤保险基金所面临的安全问题,并围绕相关问题提出解决办法,包括:政府责任、"以罚充养"、减少用人单位不参保的数量。     

Medicare program; establishing procedures for transmitting information between Medicare carriers and Medicare supplemental insurers--HCFA. General notice

This notice announces and describes the procedure for the automatic transfer of claims information from Medicare carriers to Medicare supplemental (Medigap) insurers when a beneficiary has assigned his or her right of payment to a participating physician or supplier. It delineates the roles of the Medicare carriers, Medigap insurers, State insurance departments, beneficiaries, physicians and suppliers, and HCFA. The procedure for the automatic transfer of claims is required by section 1842(h)(3)(B) of the Social Security Act, as added by section 4081(a) of the Omnibus Budget Reconciliation Act of 1987 and is intended to speed payment of Medicare supplemental insurance benefits to participating physicians and suppliers.     

保险人代位权与被保险人求偿权竞合时的处理规则

2009年修订的《保险法》对保险人代位追偿权与被保险人损害赔偿请求权竞合时的行使方式和程序方面并没有作明确规定。在这方面,当下的保险法理论和域外实务中大致采用两种做法:一种是不承认保险人代位权与被保险人求偿权的竞合关系,在被保险人获得足额补偿之前不允许保险人行使代位求偿权;另一种是承认保险代位权与求偿权的竞合,但对代位追偿所得又分别实行包括"比例分配"和"被保险人优先分配"在内的4种分配方式。应当在肯定两种相列竞合的情况下,对于足额保险可采用比例分配的方式;在不足额保险中,比例分配规则的逻辑前提是保险合同中对不足额保险约定了比例分摊的条款,如果保险合同对不足额保险是采用"比例赔偿"之外的"第一危险赔偿"方法,则对追偿所得的分配就应当改而采用"被保险人优先"的分配方式。     

Insurance Law Reform by Degrees: Late Payment and Insurable Interest

Over the last 11 years, the Law Commission and the Scottish Law Commission have worked on a joint project to modernise the law of insurance contracts. Due to the size of the project, the Law Commissions proceeded in phases and separated out specific issues for legislative reform. Their proposals have already resulted in the Consumer Insurance (Disclosure and Representations) Act 2012 and the Insurance Act 2015 which brought about significant changes for consumer and non‐consumer insureds and insurers alike. This paper examines two further areas of reform: the introduction of an implied term about payment of insurance claims by insurers within a reasonable time and a statutory restatement of the doctrine of insurable interest. It considers the old and new substantive law and provides an insight into the reform process.     

Are insurance companies liable under the Americans with Disabilities Act?

Federal courts have split on the question of the applicability of the Americans with Disabilities Act to insurance coverage decisions that insurance companies make on the basis of disability; they have similarly split on other issues pertaining to the scope of that Act's application. In deciding whether to read the Act as prohibiting discrimination in insurance decisions that are often crucial in the lives of people with disabilities, courts have faced two problems. First, where it prohibits discrimination in the equal enjoyment of the goods and services of places of public accommodation, the Act's area of concern may be limited to the ability of people with disabilities to gain physical access to facilities; or that area may extend to all forms of disability-based discrimination in the provision of goods and services. This Comment argues that the language and legislative history of the Act are consistent only with the latter view. Second, the provision limiting the Act's applicability to insurance may create an exemption for all insurance decisions; or it may protect only the ability of an insurance company to make an insurance decision to the disadvantage of an insured with a disability where actuarial data support the decision. This comment argues that the ambiguous language of the limiting provision should be resolved in favor of the latter view. Legislative history and the broader background of the history of insurance discrimination law support this resolution. Consequently, the Act should be interpreted as prohibiting disability-based discrimination by insurance companies in selling insurance policies and as defining discrimination as making disability-based insurance decisions without the support of actuarial data. By accepting this interpretation, courts can help stop the pattern of judicial narrowing of the Act's application through inappropriately restrictive statutory construction.     

The false claims act and the eroding scienter in healthcare fraud litigation

This article addresses the federal government's expansive methods in tackling healthcare fraud, particularly in misapplying the False Claims Act. Although tasked with the obligation to curtail the fraudulent submission of Medicare & Medicaid claims, the U.S. government must rein in the current trend to utilize the False Claims Act against smaller medical providers. As the Act's original focus has ebbed in significance, the government has increasingly applied the False Claims Act to circumstances that do not evince actual fraud. In doing so, federal courts have effectively eroded the statute's critical scienter requirement. The federal common-law doctrines of "payment by mistake" and "unjust enrichment" adequately address the payment of non-fraudulent, albeit false, Medicare & Medicaid claims. Yet the federal government pursues these appropriate remedies only rarely and in the alternative, essentially when the government fails under the False Claims Act. Thus, this article argues for reform, calling for a clearer delineation between remedial and punitive measures. In cases involving smaller medical providers, courts should strictly limit the False Claims Act to those instances where fraud is clearly manifest.     

When methods meet politics: how risk adjustment became part of Medicare managed care

Health-based risk adjustment has long been touted as key to the success of competitive models of health care. Because it decreases the incentive to enroll only healthy patients in insurance plans, risk adjustment was incorporated into Medicare policy via the Balanced Budget Act of 1997. However, full implementation of risk adjustment was delayed due to clashes with the managed care industry over payment policy, concerns over perverse incentives, and problems of data burden. We review the history of risk adjustment leading up to the Balanced Budget Act and examine the controversies surrounding attempts to stop or delay its implementation during the years that followed. The article provides lessons for the future of health-based risk adjustment and possible alternatives.     

Does the Statutory Regulation of Advance Decision-Making Provide Adequate Respect for Patient Autonomy?

This paper considers advance decision-making in the context of healthcare. The common law recognition of advance decisions is contrasted with new statutory provision. This paper will examine the Mental Capacity Act 2005 framework for advance decisions and lasting powers of attorney. The ‚best interests’ test and substituted judgment as criteria for proxy decision-making are compared by application to a case example. The paper examines the statutory safeguards in respect of refusals of ‚life-sustaining treatment’ and postulates that these safeguards may render respect for autonomous advance decision-making difficult to achieve in practice.     

Medicare program; prospective payment system for hospital outpatient services--HCFA. Proposed rule

As required by sections 4521, 4522, and 4523 of the Balanced Budget Act of 1997, this proposed rule would eliminate the formula-driven overpayment for certain outpatient hospital services, extend reductions in payment for costs of hospital outpatient services, and establish in regulations a prospective payment system for hospital outpatient services (and for Medicare Part B services furnished to inpatients who have no Part A coverage). The prospective payment system would simplify our current payment system and apply to all hospitals, including those that are excluded from the inpatient prospective payment system. The Balanced Budget Act provides for implementation of the prospective payment system effective January 1, 1999, but delays application of the system to cancer hospitals until January 1, 2000. The hospital outpatient prospective payment system would also apply to partial hospitalization services furnished by community mental health centers. Although the statutory effective date for the outpatient prospective payment system is January 1, 1999, implementation of the new system will have to be delayed because of year 2000 systems concerns. The demands on intermediary bill processing systems and HCFA internal systems to become compliant for the year 2000 preclude making the major systems changes that are required to implement the prospective payment system. The outpatient prospective payment system will be implemented for all hospitals and community mental health centers as soon as possible after January 1, 2000, and a notice of the anticipated implementation date will be published in the Federal Register at least 90 days in advance. This document also proposes new requirements for provider departments and provider-based entities. These proposed changes, as revised based on our consideration of public comments, will be effective 30 days after publication of a final rule. This proposed rule would also implement section 9343(c) of the Omnibus Budget Reconciliation Act of 1986, which prohibits Medicare payment for nonphysician services furnished to a hospital outpatient by a provider or supplier other than a hospital, unless the services are furnished under an arrangement with the hospital. This section also authorizes the Department of Health and Human Services' Office of Inspector General to impose a civil money penalty, not to exceed $10,000, against any individual or entity who knowingly and willfully presents a bill for nonphysician or other bundled services not provided directly or under such an arrangement. This proposed rule also addresses the requirements for designating certain entities as provider-based or as a department of a hospital.     

Medicare program; prospective payment system for long-term care hospitals: implementation and FY 2003 rates. Final rule

This final rule establishes a prospective payment system for Medicare payment of inpatient hospital services furnished by long-term care hospitals (LTCHs) described in section 1886(d)(1)(B)(iv) of the Social Security Act (the Act). This final rule implements section 123 of the Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999 (BBRA) and section 307(b) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). Section 123 of the BBRA directs the Secretary to develop and implement a prospective payment system for LTCHs. The prospective payment system described in this final rule replaces the reasonable cost-based payment system under which LTCHs are currently paid.     

Medicare program; fee schedules for the services of certified registered nurse anesthetists--HCFA. Final rule

We are revising the Medicare regulations to allow certified registered nurse anesthetists (CRNAs) to receive Medicare payment for the anesthesia services and related care they furnish. In addition, this final rule sets forth the fee schedules under which payment is made for the services of CRNAs, except for the services of CRNAs in certain rural hospitals who are paid on a reasonable cost basis. This rule, which is effective for services furnished on or after January 1, 1989, implements section 9320 of the Omnibus Budget Reconciliation Act of 1986, as amended by section 4084 of the Omnibus Budget Reconciliation Act of 1987, section 411(i)(3) of the Medicare Catastrophic Coverage Act of 1988, section 608(c) of the Family Support Act of 1988, and sections 6106, 6107 and 6132 of the Omnibus Budget Reconciliation Act of 1989. This final rule does not reflect the changes concerning the calculation of payment rates contained in section 1833(1)(4) of the Social Security Act, as enacted by section 4160 of the Omnibus Budget Reconciliation Act of 1990. Those changes apply to services furnished on or after January 1, 1991. Thus, the changes to the payment calculation provisions described and published below are applicable only to services furnished in calendar years 1989 and 1990.