Nội dung toàn văn Decision No. 05/TC/BH promulgation disability insurance coverage rates personal insurance operations
THE MINISTRY OF FINANCE | SOCIALIST REPUBLIC OF VIETNAM |
No. 05/TC/BH | Hanoi, January 2, 1993 |
DECISION
PROMULGATION OF THE SCHEDULE OF DISABILITY INSURANCE COVERAGE RATES APPLYING TO PERSONAL INSURANCE OPERATIONS
THE MINISTER OF FINANCE
- Pursuant to the Decree No. 155/HDBT dated 15-10-1988 of the Ministerial Council on definition of functions, duties and organizational structure of the Ministry of Finance;
- Pursuant to the Decision No. 45/QDTC dated 2-3-1989 of the Minister of Finance on introduction of the organizational and operational charter of Vietnam Insurance Incorporation;
For the purposes of providing the uniform method of insurance payment made in personal insurance operations;
After considering the request of the General Director of Vietnam Insurance Incorporation;
HEREBY DECIDES
Article 1: This Decision is enclosed herewith the schedule of disability insurance coverage rates applying to personal insurance operations.
Article 2: This Decision shall enter into force from the signature date. Any preexisting regulations relating to disability insurance payments that apply to personal insurance operations in contravention of this Decision shall be rendered null and void.
Article 3: The General Director of Vietnam Insurance Incorporation, the Chief of the Ministry of Finance’s Office, the Director of the Department of Financial Balancing – Finance, the Directors of the Finance Departments of centrally-affiliated cities and provinces, and Heads of relevant agencies, shall be responsible for enforcing this Decision./.
| PP. THE MINISTER OF FINANCE |
SCHEDULE OF DISABILITY INSURANCE COVERAGE RATES
(Issued together with the Decision No. 05/TC-BH dated 2/01/1993 of the Ministry of Finance)
Scope of benefits | Insurance coverage rate |
I – TOTAL DISABILITY | 100% |
1. Blindness or total loss of two eyes | 100% |
2. Incurable psychological disorder | 100% |
3. Total impairment of chewing and talking capacity | 100% |
4. Total loss or paralysis of two arms (from the shoulders or elbows) or two legs (from the crotch or knees) | 100% |
5. Loss of two hands or two feet, one arm and one foot, or one arm and one shank, or one hand and one shank, or one hand and one foot | 100% |
6. Loss of ability to work (complete paralysis, injuries that lead to immobilization or total permanent disability) | 100% |
7. Removal of a complete lung and a part of the other lung | 100% |
II – PARTIAL DISABILITY |
|
A. UPPER LIMBS |
|
8. Loss of one arm from the shoulder (shoulder disarticulation) | 75 – 85% |
9. Amputation of an arm below the shoulder | 70 – 80% |
10. Amputation of one arm at the elbow (elbow disarticulation) | 65 – 75% |
11. Loss of a complete hand or five fingers | 60 – 70% |
12. Loss of 4 fingers, except the thumb | 40 – 50% |
13. Loss of the thumb and index finger | 35 – 45% |
14. Loss of 3 fingers: 3rd, 4th and 5th ones | 30 – 35% |
15. Loss of 1 thumb and 2 other fingers | 35 – 40% |
16. Loss of 1 thumb and 1 other finger | 30 – 35% |
17. Loss of 1 index finger and 2 other fingers | 35 – 40% |
18. Loss of 1 index finger and 1 middle finger | 30 – 35% |
19. Loss of one thumb and one metacarpal | 25 – 30% |
Loss of one thumb Loss of the distal phalange Loss of ½ of the distal phalange | 20 – 25% 10 – 15% 07 – 10% |
20. Loss of one index finger and one metacarpal Loss of 1 index finger Loss of 2nd and 3rd phalange Loss of 3rd phalange | 20 – 25% 18 – 22% 10 – 12% 08 – 10% |
21. Complete loss of 1 middle finger or ring finger (a whole metacarpal) Loss of 1 middle finger or ring finger Loss of 2nd and 3rd phalange Loss of 3rd phalange | 18 – 22% 15 – 18% 08- 12% 04 – 07% |
22. Loss of 1 little finger and metacarpal Loss of a complete little finger Loss of 2nd and 3rd phalange Loss of 3rd phalange | 15 – 20% 10 – 15% 08 – 10% 04 – 07% |
23. Stiff shoulder joint 24. Stiff elbow joint 25. Stiff wrist | 25 – 35% 25 – 35% 25 – 35% |
26. Fractured arm distraction or bone loss that shortens the limb by more than 3 cm and impedes the ability to turn the palm up and down or creates false joints | 25 – 35% |
27. Arm bone fracture at the anatomical neck, bad callus, limited movement of shoulder joints 28. Fracture of wrist bones - Good callus, normal movement - Bad callus, atrophy 29. Fracture of the radius and ulna 30. Fracture of either radius or ulna 31. False joint of both radius and ulna | 35 – 45%
15 – 25% 25 – 30% 12 – 25% 10 – 20% 25 – 35% |
32. False joint of either radius or ulna 33. Fracture of the lower extremity of the radius 34. Fracture of the styloid process of the radius or ulna 35. Fracture of wrist bones 36. Fracture of metacarpals (depending on the fracture level ranging from 1 to many metacarpals) 37. Fracture of collar bone: Good callus Bad callus, stiff shoulder Compression of axilarry nerve 38. Scapula fracture: - Fractured or missing main part of scapula - Horizontal fracture - Shoulder joint fracture 39. Fracture of finger bones (depending on fracture level ranging from one to many fingers) | 15 – 20% 10 –18% 08 – 15% 10 – 18% 08 – 15% 08 – 12% 18 – 25% 30 – 35% 10 – 15% 17 – 22% 30 – 40% 03 – 12% |
B. LOWER LIMBS |
|
40. Loss of one leg from the crotch (hip disarticulation) 41. Amputation of one thigh: 1/3 upper 1/3 middle or below 42. Amputation of 1 leg below the knee (knee disarticulation) 43. Ankle disarticulation or loss of 1 foot 44. Loss of talus 45. Loss of calcaneus 46. Loss of part of the tibia, fibula that causes false joints 47. Partial loss of the fibula 48. Loss of ankles: - Outer ankle - Inner ankle 49. Loss of all 5 toes 50. Loss of 4 toes including the big toe 51. Loss of 4 toes excluding the big toe 52. Loss of 3rd, 4th and 5th toe 53. Loss of 3 toes including 1st, 2nd and 3rd toe 54. Loss of the big toe and 2nd toe 55. Loss of 1 big toe 56. Loss of 1 toe excluding the big toe 57. Loss of 1 big toe phalanx 58. Hip stiffness 59. Knee joint stiffness | 75 – 85%
70 – 80% 55 – 75% 60 – 70% 55 – 65% 35 – 40% 35 – 45% 35 – 45% 20 – 30%
10 – 15% 15 – 20% 45 – 55% 38 – 48% 35 – 45% 25 – 30% 30 – 35% 20 – 25% 15 – 20% 10 – 15% 08 – 12% 45 – 55% 30 – 40% |
60. Loss of most of the patella and serious limitation to the ability to stretch the upper thigh | 45 – 55% |
61. Leg fracture distraction or loss of bone that leads to the limb shortening - by 3 - 5 cm - from 3 to 5 cm 62. Complete paralysis of lateral popliteal nerve 63. Complete paralysis of medial popliteal nerve 64. Fracture of thigh bone at 1/3 middle or below - Good callus - Bad callus, malunion, varus or valgus, atrophy (In case of surgery, the maximum amount of insurance coverage shall be paid) 65. Fracture of the upper 1/3 or femur neck (in case of surgery, the maximum amount of insurance coverage shall be paid) - Good callus, straight axis - Bad callus, valgus, walking with pain, atrophy 66. False joint of the femur neck 67. Fracture of the fibula and tibia 68. Fracture of the tibia 69. Fracture of the tibial plateau 70. Fracture of the fibula 71. Patellar tendon rupture 72. Fracture of the patella (in case of surgery, the maximum amount of insurance coverage shall be paid) 73. Fracture of the patella, knee stiffness, or quadriceps atrophy (depending on disability levels) 74. Achilles tendon rupture (stitched) 75. Fracture of metacarpals (depending on the level ranging from 1 to many metacarpals) 76. Fracture of the calcaneus 77. Fracture of the navicular 78. Fracture of toe bones (depending on the level ranging from 1 to many phalanges) 79. Fracture of ramus superior ossis pubis 80. Fracture of the ischium 81. Fracture of 1 ilium 82. Fracture of 2 ilium, pelvic deformity (depending on the level of impact on reproduction) |
40 – 45% 35 – 40% 35 – 45% 25 – 35%
20 – 30% 30 – 40%
25 – 35% 35 – 45% 45 – 55% 20 – 30% 15 – 22% 15 – 25% 10 – 20% 15 – 25% 10 –20% 25 – 30% 15 – 20% 07 – 12% 15 – 25% 15 – 22% 04 – 12% 25 – 32% 25 – 30% 20 – 30% 40 – 60% |
83. Fracture of the sacrum: Without a sphincter disorder. With a sphincter disorder. |
10 – 15% 25 – 35% |
C. SPINE 84. Removal of posterior vertebral arch: of 1 vertebra of 2 – 3 vertebrae or more 85. Compression fracture of 1 vertebra (without paralysis of the spinal cord) 86. Compression fracture of more than 2 vertebrae or more (without paralysis of the spinal cord) 87. Fracture of the spinous process or transverse process of 1 vertebra of 2 – 3 vertebrae |
35 – 40% 45 – 60% 30 – 40% 45 – 60%
10 – 17% 25 – 45% |
D. SKULL AND BRAIN 88. Skull defect (no sign of psychological and psychiatric disorder) + Diameter < 6 cm + Diameter from 6 - 10 cm + Diameter > 10 cm 89. Language disorder due to brain injuries + Idioglossia or spasmophemia that affect communication Mutism due to injury to the Broca’s area + Loss of ability to use written language (asphasia due to injury to the Wernicke’s area) |
25 – 40% 40 – 60% 50 – 70%
30 – 40% 60 – 70% 55 – 70% |
90. Total scalping (or partial scalping according to ratios) 91. Open head injuries: Cracked or broken skull Depressed skull Deep penetration of many pieces of fractured bones into the brain 92. Closed head injury + Fracture of calvaria (usual crack or depressed fracture) + Bone fracture that spreads to the basilar skull without paralysis of cranial nerve + Bone fracture that spreads to the basilar skull with paralysis of cranial nerve 93. Brain injury + Cerebral concussion + Cerebral edema + Cerebral contusion, compression + Subarachnoid hemorrhage + Intracranial haematoma (epidural, subdural and intracerebral) | 45 – 55%
40 – 50% 30 – 40% 50 – 60%
20 –30% 30 – 40% 40 – 50%
08 – 15% 40 – 50% 50 – 60% 40 – 50% 30 – 40% |
E. CHEST 94. Removal of 1 – 2 ribs 95. Removal of 3 ribs or more 96. Removal of each rib section 97. Fracture of 1 – 2 ribs 98. Fracture of 3 ribs or more 99. Mere fracture of the sternum (cardiovascular and refractory functions are normal) 100. Fissure of the sternum 101. Complete removal of one lung 102. Removal of multiple lobes of 2 lungs, DTS is reduced by over 50% |
15 – 20% 25 – 35% 8 – 10% 7 – 12% 15 – 25% 15 – 20% 10 – 15% 70 – 80% 65 – 75% |
103. Removal of multiple lobes of a lung 104. Removal of a lung lobe 105. Pleural effusion, pneumothorax, hemothorax (paracentesis only) 106. Pneumothorax, hemothorax (drainage) 107. Heart valve and septum defects due to injuries (without a heart failure) 108. Pericardial sewing: Bad surgery result Good surgery result | 50 – 60% 35 – 45% 04 – 10% 20 – 30% 50 – 60%
60 – 70% 35 – 45% |
G. ABDOMEN 109. Complete removal of the stomach 110. Segmental resection of the stomach 111. Removal of most of the small intestine (less than 1 m remaining) 112. Segmental resection of the small intestine 113. Complete removal of the large intestine 114. Segmental resection of the large intestine 115. Mere removal of the right liver 116. Mere removal of the left liver 117. Removal of liver lobes, depending on the position, number, and surgery results 118. Removal of the gall bladder 119. Removal of the spleen 120. Removal of the tail of pancreas or spleen 121. Gastric perforation sewing 122. Small intestine perforation sewing (1 or multiple perforations) 123. Large intestine perforation sewing 124. Liver contusion, liver sewing 125. Splenic capsule sewing 126. Pancreas sewing |
75 – 85% 50 – 60% 75 – 85% 40 – 50% 75 – 85% 50 – 60% 70 – 80% 60 – 70% 40 – 60% 45 – 55% 40 – 50% 60 – 70% 25 – 35% 30 – 45% 30 – 40% 35 – 45% 25 – 35% 30 – 35% |
H. UNIRARY AND REPRODUCTIVE ORGANS 127. Removal of 1 kidney, the remaining kidney is functional 128. Removal of 1 kidney, the remaining kidney is damaged or sick 129. Segmental resection of the left or right kidney 130. Kidney injury (depending on the seriousness and the number of kidneys injured) Slight (not special treatment is required, shorter than 5 days of monitoring) Medium (special medication is required, longer than 5 days of monitoring) Serious (contusion, surgical intervention is required) 131. Segmental resection of the bladder 132. Permanent bladder stoma surgery 133. Bladder perforation sewing |
50 – 60% 70 – 80% 30 – 40%
04 – 08% 10 – 15% 47 – 55% 27 – 35% 70 – 80% 30 – 35% |
134. Loss of the penis and 2 testicles of: A woman under 55 years of age without children A women under 55 years of age with children A women over 55 years of age 135. Removal of the womb and one ovary of Women under 45 years of age without children Women under 45 years of age with children Women over 45 years of age 136. Removal of 1 breast of women under 45 years of age: 1 side 2 sides Women over 45 years of age 1 side 2 sides |
70 – 80% 55 – 65% 35 – 40%
60 – 70% 30 – 40% 25 – 30% 20 – 30% 45 – 55% 15 – 20% 30 – 40% |
I. EYE 137. Loss or total loss of sight of 1 eye Failure to implant an artificial eye Possibility of implantation of an artificial eye 138. The 1/10 vision of one eye 139. The 2/10 – 4/10 vision of one eye 140. The 5/10 – 7/10 vision of one eye 141. Loss or total loss of sight of 1 eye, but the other eye is already lost or blind before the accident |
55 – 65% 50 – 60% 30 – 45% 12 – 20% 07 – 15% 80 – 90% |
K. EAR – NOSE - THROAT 142. Deafness of 2 ears: unrecoverable Serious (able to hear when being screamed at) Medium (able to hear loud voices at 1 – 2 m) Slight (able to hear loud voices at 2 – 4 m) 143. Deafness of 1 ear: unrecoverable Medium Slight 144. Loss of 2 pinna 145. Loss of 1 pinna 146. Shriveled pinnae, ear canal stenosis 147. Loss of nose, nose deformity 148. Esophageal stricture causing swallowing difficulties |
75 – 85% 60 – 70% 35 – 45% 15 – 25% 30 – 40% 15 – 20% 8 – 15% 20 – 40% 10 – 25% 20 – 25% 18 – 40% 20 – 40% |
L. TOOTH – JAW – FACE 149. Lost of part of the upper jawbone and part of the lower jawbone from the ramus and under: at a different side at the same side 150. Total loss of the upper jawbone or lower jawbone 151. Loss of part of the upper jawbone or part of the lower jawbone (1/3 – 1/2 of the jawbone is lost) under the ramus |
80 – 90% 70 – 80% 70 – 80% 35 – 45%
|
152. Fracture of the upper jawbone and the lower jawbone, mal union, dislocation of temporomandibular joint which cause swallowing and chewing difficulties 153. Fracture of the zygomatic bone, which causes slight the temporomandibular joint disorder and chewing difficulties | 30 – 35% 15 – 25% |
154. Artificial temporomandibular joint due to nonunion or bone defects 155. Loss of teeth: more than 08 teeth without possibility of implantation of false teeth From 5 – 7 teeth From 3 – 4 teeth From 1 – 2 teeth 156. Loss of 3/4 of the tongue without losing the root (from the V line outwards) 157. Loss of 2/3 of the tongue from the tip 158. Loss of 1/3 of the tongue that causes pronunciation difficulties 159. Loss of less than 1/3 of the tongue that causes pronunciation difficulties | 20 – 25% 30 – 40% 15 – 25% 8 – 12% 3 -6 % 75 – 85% 50 – 60% 15 – 25% 10 – 15% |
M. SOFT TISSUE INJURIES, BURNS 160. Soft tissue injuries include skin scratch, mucous membrane scratch, sprain, luxation, etc. which causes no impact on muscular energy (depending on the seriousness level such as serious, slight, much or less) 161. Soft tissue injuries that cause pain, numbness, convulsive movements (depending on the extent and seriousness), affect tendons, muscles, major blood vessels, and nerves 162. Chest and abdominal soft tissue injuries that affect respiration 163. Soft tissue injuries that leave sclerosis and cause difficulties in eating, chewing, and neck movement 164. Soft tissue injuries that cause large openings around the mouth cavity, lip and cheek injuries that seriously affect eating and drinking 165. Loss of part of the palate that connect the nose and the mouth 166. Superficial burn (first-degree, second-degree) Less than 5% of skin area From 5-15% and more than 15% of skin area 167. Deep burn (third-degree, fourth-degree, fifth-degree) Less than 5% of skin area 5-15% of skin area More than 15% of skin area |
02 – 12%
40 – 60%
3 – 7% 10 – 15% 15 – 25% 20 – 35% 35 – 60% 60 – 80% |
PRINCIPLES OF INSURANCE CLAIM CONSIDERATION
Insurance claim consideration according to this schedule shall be based on insured patients’ medical treatment invoices and the following regulations:
1- The complete incapacity of each organ or permanent limb damage shall be considered as loss of such organ or loss of limbs.
When any disability is not specified in this schedule, claims on such disability shall be paid based on the comparison of its seriousness with other disability cases defined in this schedule.
3- Commonly treated injuries and those without infection shall be eligible for insurance payments in proportion to the lowest level of insurance payment in the scale of insurance coverage rates applicable to this case.
4- Complicatedly treated injuries and those with infection or with any sequela after being treated shall be based on their seriousness to be eligible for insurance payments which are gradually increased to the maximum level of insurance payment in the scale of insurance payment coverage applicable to this case.
5- With respect to multiple injuries, insurance payments shall be made to single injury but the total of insurance payment to the insured is not allowed to exceed the insurance cover agreed in an insurance policy. If multiple injuries occur at the same limb, the total sum paid to such injuries is not allowed to exceed the ratio of such limb loss.
6- With respect to injuries subject to re-operation and breaking of callus for remodeling, 50% of the minimum level of insurance payment in the scale of insurance coverage rate applied to such case shall be additionally paid but the total sum of insurance payment is not allowed to exceed the insurance cover agreed in an insurance policy.
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