Thông tư liên tịch 39/2011/TT-BYT-BTC

JOINT CIRCULAR

GUIDING THE PROCEDURES FOR PAYMENT OF MEDICAL EXAMINATION AND TREATMENT EXPENSES FOR HEATH INSURANCE PARTICIPANTS MEETING WITH TRAFFIC ACCIDENTS

Pursuant to the November 14, 2008 Law on Insurance Health;

Pursuant to the November 13, 2008 Law on Road Traffic;

Pursuant to the June 14, 2005 Law on Railway Traffic;

Pursuant to the June 15, 2005 Law on Waterway Traffic;

Pursuant to the Government's Decree No. 62/2009/ND-CP of July 27, 2009, detailing and guiding a number of articles of the Law on Health Insurance;

The Ministry of Health and the Ministry of Finance guide procedures for payment of medical examination and treatment expenses for health insurance participants meeting with traffic accidents as follows:

Article 1. General principles

1. Pending the collection of sufficient grounds to determine whether or not a traffic accident occurred due to the accident victim's violation of traffic rules, when receiving medical care, the accident victim who is a health insurance participant will be eligible for health insurance benefits according to regulations.

2. When there are sufficient grounds to determine that a traffic accident occurred due to the accident victim's violation of traffic rules or a traffic accident victim falls outside the payment coverage of the health insurance fund, such accident victim will be ineligible for health insurance benefits and must fully refund medical examination and treatment expenses to the health insurance fund.

3. The following persons will be eligible for health insurance-covered medical care according to regulations without having to go through the procedures for determining violations of traffic rules prescribed in Article 2 of this Circular:

a/ Children aged under 14;

b/ Elderly persons aged 80 or older.

Article 2. Order, procedures and responsibilities for determining violations of traffic rules

1. For health insurance participants meeting with traffic accidents:

When seeking medical care, a health insurance participant meeting with a traffic accident shall, apart from producing papers required for health insurance-covered medical care, provide to the medical examination and treatment establishment information on his/her full name, date of birth; place of residence; time and place of the accident and cause of the accident (if any).

In case the accident victim has fallen into a coma and is unable to provide the above-mentioned information, his/her relatives or persons who escort the victim to the hospital shall provide information on what they know about the accident.

When acquiring any of the documents specified in Article 3 of this Circular, the accident victim or his/her relatives shall immediately hand over such document to the medical examination and treatment establishment for use as a ground for payment of medical examination and treatment expenses according to health insurance regulations.

2. For medical examination and treatment establishments receiving accident victims:

Everyday, medical examination and treatment establishments shall make a list of health insurance participants meeting with traffic accidents who come for medical examination or treatment or emergency treatment on the day (according to the form provided in Appendix 1 to this Circular, not printed herein) and transfer such list to social security agencies or social security officers based in their establishments.

3. For social security agencies:

a/ Within 2 working days after receiving a list of health insurance card holders meeting with traffic accidents from a medical examination and treatment establishment, a social security agency shall send written requests for verification of accident victims' violations of traffic rules to the traffic police offices or social order-related crime investigation police offices (below collectively referred to as police offices) of the localities where the traffic accidents occurred (according to the form provided in Appendix 2 to this Circular, not printed herein).

In case an accident victim or his/her relative has provided the medical examination and treatment establishment or social security agency with one of the documents mentioned in Article 3 of this Circular or the social security agency has previously sent a written verification request, the social security agency is not required to re-send such request.

b/ Three months after a verification request is sent, if the social security agency receives no reply from the police office or receives a notice informing that the police office has not yet investigated or is incapable of investigating into violations of traffic rules, the social security agency shall pay and settle medical examination and treatment expenses as for cases in which accident victims do not violate traffic rules.

Article 3. Grounds for payment or non­payment of medical examination and treatment expenses for health insurance participants meeting with traffic accidents according to regulations

Social security agencies shall base themselves on any of the following documents to decide whether or not to pay medical examination and treatment expenses for health insurance participants meeting with traffic accidents:

1. Copy of the traffic accident minutes made by a police office.

2. Copy or extract of the accident investigation report containing the certification of the police office that has received and handled the case.

3. Copy or extract of the final conclusion of the court that has handled the case (containing the court's certification), provided by the accident victim or his/her relative.

Article 4. Payment of medical examination and treatment expenses for traffic accidents involving violations of traffic rules

When there are sufficient grounds to determine that a traffic accident occurred due to the accident victim's violation of traffic rules, the social security agency shall pay medical examination and treatment expenses as follows:

1. If the victim is being treated at a medical examination and treatment establishment, the social security agency shall notify the victim or his/her relative (natural parent, spouse or natural child of full 18 years or older) that the victim violated traffic laws and is ineligible for payment of medical examination and treatment expenses from the health insurance fund.

2. If the victim has been discharged from hospital, the social security agency shall recover medical examination and treatment expenses already paid by the health insurance fund under Article 5 of this Circular.

3. If the victim dies, the social security agency shall pay and settle medical examination and treatment expenses with the medical examination and treatment establishment according to health insurance regulations (in this case, the paid expenses are not recovered).

Article 5. Recovery of medical examination and treatment expenses already paid by the health insurance fund

1. The social security agency shall notify the accident victim or his/her relative of the results of verification of violation of traffic rules by the police office and request him/her to refund medical examination and treatment expenses already paid by the social security agency to the health insurance fund (according to the form provided in Appendix 3 to this Circular, not provided herein).

2. Thirty days after the first refund request is sent, if the accident victim or his/her relative fails to refund the paid expenses, the social security agency shall issue a follow-up notice to further request the refund.

3. Three months after the follow-up notice is sent under Clause 2 of this Article, if the victim or his/her relative still fails to refund the paid expenses, the social security agency shall report the case to its superior-level agency for summarization and reporting to Vietnam Social Security.

4. At the end of the fiscal year, Vietnam Social Security shall sum up and report all medical examination and treatment expenses which have been paid for health insurance participants meeting with traffic accidents but cannot be recovered to the Ministry of Health for the latter to, in coordination with the Ministry of Finance, propose the Prime Minister to permit the settlement of these expenses with the health insurance fund.

Article 6. Effect

1. This Circular takes effect on December 26,2011.

2. To annul Clause 3, Article 8 of Joint Circular No. 09/2009/TTLT-BYT-BTC of August 14, 2009, of the Ministry of Health and the Ministry of Finance, guiding the implementation of health insurance, on the effective date of this Circular.

Article 7. Organization of implementation

1. To assign Vietnam Social Security to promulgate the form of the report on medical examination and treatment expenses which have been paid but cannot be recovered mentioned in Clause 3, Article 5 of this Circular and guide social security agencies of all levels in implementing this Circular.

2. This Circular also applies to health insurance participants who met with traffic accidents before the effective date of this Circular and are receiving treatment at medical examination and treatment establishments.

Any problems arising in the course of implementation should be reported to the Ministry of Health and the Ministry of Finance for study and settlement.-