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PUBLISHED DATE: - 09-10-2024
DOI: -
https://doi.org/10.37547/tajpslc/Volume06Issue10-03
PAGE NO.: - 16-22
THE ROLE OF MEDICAL INSURANCE IN THE
FIELD OF HEALTH CARE AND LEGAL ISSUES
OF ITS IMPLEMENTATION
Mansurjon Boltaev
Tashkent State University of Law, Associate Professor of the Department of
Civil Law, doctor of legal sciences, Uzbekistan
INTRODUCTION
All areas of law in the maintenance and provision
of human health provide for a certain level of
protection and protection measures, and
determine the implementation of such provision
through various mechanisms. For example, by
defining the rights and obligations of health care
system organizations, introducing organizational
and legal mechanisms for providing qualified
medical services to patients, establishing
responsibility for health injuries, and providing for
the powers of state bodies in this regard. the
spheres of law envisage the legal procedure of
maintaining and ensuring the health of citizens. At
the same time, ensuring the health of every citizen
by determining the targeted and individually
oriented measures of ensuring human health is of
particular importance today. As such a measure,
the Institute of Medical Insurance creates a unique
system of relations related to the provision of
human health and ensures the patient's right to use
RESEARCH ARTICLE
Open Access
Abstract
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guaranteed medical services in treatment facilities.
By taking out his health insurance, a citizen has the
right to demand that the insurance organization
reimburses him for the costs of treatment in the
future when his health deteriorates or he becomes
ill. In addition, as an object of medical insurance, it
may be provided that a citizen undergo a medical
examination within a certain period and with a
referral from a doctor of a medical institution, as
well as cover the costs of diagnostics and medical
consultation[1]. In this situation, the provision of
medical services is considered an object of medical
insurance, and the costs of providing medical
services to a citizen who has health insurance are
reimbursed by the insurance organization.
Law of the Republic of Uzbekistan "On Insurance
Activities" in Article 4, insurance is divided into life
insurance and general insurance[2]. Medical
insurance belongs to the field of life insurance. In
the Civil Code (hereinafter - CC), life insurance is
defined as personal insurance. Damage to life or
health is provided as the object of the personal
insurance contract. In addition, it is stipulated in
the first part of Article 921 of the CC that the
occurrence of another event (insurance event)
included in the contract with the agreement of the
parties in the life of the insured person is also
considered an object of personal insurance.
Above, it can be seen from the correlation and
analysis of the norms that there is no clarity in the
legislation regarding whether medical insurance
belongs to one of the two types of insurance
contracts - property or personal insurance, and
what constitutes its object.
Legal literature does not have unanimous opinions
and understandings about the role of medical
insurance. A group of scholars note that health
insurance is often misconstrued as liability
insurance and indemnity insurance [4]. Another
group of experts interpret health insurance as a
type of personal insurance contract[5]. Some
researchers come to the conclusion that medical
insurance directly implies the obligations of the
medical institution, and that the object is the
insured's property interests, that is, the expenses
related to his compensation in the event of damage
to his health [6]. At the same time, in some
developing countries, health insurance is seen as a
way of financial support for the population, and in
the conditions of high cost of medical services, this
method is used as a measure to support the low-
income segment of the population. is evaluated [7].
In our opinion, health insurance is socially oriented
and differs from the usual forms of personal and
property insurance. From the point of view of its
object, it is appropriate to interpret medical
insurance as a type of personal insurance. Because,
in medical insurance, as an insurance event, food
related to the maintenance of human health: a
complex
of
medical
services
(diagnosis,
consultation, treatment, medical procedures and
surgery) and related to health restoration includes
direct treatment-prophylactic procedures. In this
case, unlike personal insurance, the insured person
does not receive the insurance money in the event
of damage to his health or an event provided for in
the insurance contract, but has the right to receive
free treatment and a recovery course at an
appropriate medical institution. . The advantage of
medical insurance is not only the reimbursement of
treatment costs, but also the fact that the medical
institution, the rooms and treatment courses, and
the types of treatment are determined in advance
in the contract. In this case, the medical institution,
in addition to carrying out appropriate treatment
procedures with the insured person in the event of
an insured event, includes placing him in a hospital,
taking appropriate medication and diagnostics,
conducting a full medical examination, qualified it
will be necessary to carry out complex actions such
as attracting specialists.
Commenting on the content of the medical
insurance contract, P.Z.Ivanishin states the
following: in medical insurance, the insurer has
contractual relations with the insured after
payment of the insurance premium by the insured.
undertakes the organization and financing of the
provision of medical and other health-related
services by the provider of medical services [8].
Y.V. Lazareva emphasizes that the purpose of
medical insurance is to ensure that citizens receive
medical care and finance preventive measures at
the expense of the accumulated funds in the event
of an insured event [9].
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In our opinion, the purpose of medical insurance is
not limited to the guarantor of a citizen's health
care. Medical insurance serves as a kind of
"preliminary contract for future medical services"
between the medical institution and the insured
person, and it is a constant monitoring of the
citizen's health. Therefore, medical insurance is
considered a mechanism that ensures the use of
medical services for the restoration and
maintenance of health of the insured person within
the insurance money paid by the insurer. First of
all, this situation provides the policyholder with
the use of guaranteed medical services, while
preventing unexpected necessary expenses in the
event of an insured event, for example, when his
health deteriorates. In order to conclude a medical
insurance contract, the insurer must not only enter
into contractual relations with the insured, but also
enter into contractual relations with the relevant
medical institution. Such contacts are related to the
need to provide qualified medical services to the
insured person in the event of an insured event.
In world practice, medical insurance is defined
based on insurance risks. In this case, full medical
insurance covers the following risks:
- medical expenses for the following cases:
a) treatment; b) prevention; c) rehabilitation; g)
medical and household care;
- loss of personal income due to incapacity for
work:
a) temporary; b) constant.
In the first case, the insurance covers the insured
person's necessary expenses for medical care, and
in turn, this guarantee applies to property loss
insurance and protects the client against sudden
expenses. . In the second case, the insurer pays
property insurance to the insured person for the
period of incapacity for work, and this guarantee is
considered money insurance, as it protects the
personal income of the insured person [10].
From an economic point of view, medical insurance
is a form of social protection in the field of public
health care and represents a guaranteed payment
for medical care at the expense of insurance funds
collected by the insurer in the event of an insured
event. . The development of medical insurance is
related to the need to provide comprehensively
qualified and acceptable medical services to the
population in the context of the exchange of the
concept of "free medicine" with the concept of
"medical insurance" [11]. In fact, medical insurance
is aimed at ensuring the population's need for
medicine in the provision of paid medical services,
and not in the conditions of "free medicine", and is
used in the real market economy relations of public
health care. is a tool. Of course, the level of
acceptance of medical insurance and the insurance
institute in general by the population is also
important. In many cases, citizens perceive
insurance as a negative reality, consider it
inappropriate to "think bad things instead of good
intentions, and insure that this will happen in
advance", as well as insurance As a result of
considering
the
excess
expenditure
as
unnecessary, the coverage rate of health insurance
does not have a significant increase. However, it
will be necessary to gradually apply the advantages
of medical insurance, to set the amount of
insurance premiums and contributions to a lower
level, and to carry out relevant explanatory work
for the population.
Health insurance, as a form of social protection of
the population in the field of health care,
guarantees the provision of medical care in case of
loss of health for any reason, including illness or
accident. It provides measures for the formation of
separate insurance funds intended to finance
medical care within the framework of insurance
programs. The object of medical insurance is the
insurance risk associated with the financing of
medical care in the event of an insured event.
Health insurance is based on the principle of social
solidarity in the distribution of risks, that is: the
rich pay for the poor, the healthy pay for the sick,
the young pay for the old. The following insurance
principle applies: if you are sick, you win, if you stay
healthy, you lose [12]. The insurer wins if the
insured person does not get sick and does not have
a reason to seek medical help. After all, the non-
occurrence of the insured event specified in the
insurance contract during the period of validity of
the contract frees the insurer from paying the
insurance premium and leads to the cancellation of
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the contract.
The experience of foreign countries is also
important in expressing the essence of medical
insurance. Because, by strengthening medical
insurance at the legislative level and studying the
experience of legal systems that have positive
experience in the practice of application, it
becomes possible to develop positive and effective
mechanisms of legal regulation of this type of
insurance. In this case, it is necessary to pay
attention to the fact that the regulatory system of
health care has certain differences from paid
insurance. In European countries, the principle of
social solidarity in health care continues, and in the
USA, the philosophy of strong competition and
individuality continues to rule. The type of
regulation of health insurance is related to the
adoption of legislation on compulsory insurance of
the population of European countries in the 19th -
20th centuries. In these countries, not only the rich
strata of the population participate in compulsory
health insurance. Health insurance in the US is a
private affair (except for the contingent served by
the government programs Medicare and
Medicaid), and a large portion of the low-income
population does not have access to health
insurance. will be deprived [13]. Social solidarity
based on trade unions and social-democratic
movements, religious organizations led to the
rapid development of health insurance in European
countries and the growth of health insurance
indicators in the United States. In particular, low-
income, chronically and seriously ill patients are
exempted from additional payment for health
insurance. In this case, the system provides for the
payment of a large part of the costs for drugs (in
France - 95%), glasses and prostheses (80-95%),
laboratory analysis (80-90%). In Germany,
Sweden, Belgium, the costs of transporting patients
(within the specified amount), as well as their
treatment in sanatoriums, are covered. Basic
insurance services in the US have not had a picture
of steady growth for many years.
The high level of insurance in European countries,
the wide range of medical care for insured persons
is based on the significant level of subsidies
allocated by governments, as well as the
redistribution of funds among insurance
companies. Currently, the working part of the US
population (under 65 years of age) is completely
deprived of government subsidies ("Medicaid"),
and fierce competition between insurance
companies is observed.
Usually, the regulatory system of health insurance
provides each insured person with the opportunity
to apply to any doctor or hospital for medical
services for a relatively simple fee. In the 80s and
90s of the last century, the system of hiring doctors
from Health Societies was widespread in the USA,
where the patient could only refer to these doctors.
Today, it is noted that the patient's level of freedom
to choose a doctor, treatment method, and hospital
has greatly increased.
In European countries, a system of price controls
for medical services has been developed. The law
and the practice of negotiations between insurance
companies and medical associations (sometimes
directly, in some cases with the participation of
government officials) keep prices relatively low,
and in some cases inflation-adjusted. helps to
maintain. In the US, it is noted that it is impossible
to control the price increase and the government is
helpless in this regard.
It is clear from this that the application of the
European Union model in the application of
medical insurance service, the appropriate
restraint on the medical insurance premiums and
the price of the medical services provided in the
event of the insurance event provided for in the
contract should not be high. to implement, to
prevent monopoly in this field, to receive qualified
medical services within the framework of medical
insurance and to use full medical services of the
insured person and thus to restore his health,
subject to the amount of the relevant insurance
money it is appropriate to choose a way to create a
system.
When interpreting the essence of medical
insurance, it is necessary to take into account its
scope of application and its connection with the
direct obligation. After all, when concluding a
medical insurance contract, an additional
obligation is assumed for the insurer, that is,
entering into a contractual relationship with a
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medical institution capable of providing relevant
medical services and assigning relevant obligations
to this medical institution. For this reason, medical
insurance is defined as the type of medical
institution with which the insurer entered into a
contractual relationship, unlike the usual
insurance relations, and the possibility of this
institution providing the relevant medical
procedures provided for in the insurance contract.
Subjects participating in medical insurance
relations are the citizen - the insured person, the
insured, the insurance medical organization - the
insurer, and the medical institution. According to
the rule established in the practice of insurance, the
citizen - the insured person is the beneficiary. In
other words, the main goal of the entire medical
insurance system is to guarantee the citizen's
access to medical care and to finance preventive
measures at the expense of funds collected in the
event of an insured event. In modern insurance
systems, prevention refers to measures to reduce
the scope of an insured event, and preventive
measures in a broad sense, for which the health
care systems of the state are responsible, are not
taken into account. It should be remembered that
large-scale public health measures, prevention of
various diseases, epidemics and pandemics, and
elimination of their causes are primarily the
responsibility of the state health care system. In
contrast, health insurance provides for the creation
of specific organizational, legal and financial
mechanisms for the restoration of citizens' health
and treatment. Because a unique tripartite
relationship is formed through the conclusion of a
medical insurance contract, and in the event of an
insured event between the insurer and the insured,
the insurance company is required to resolve the
organizational and legal issues of the relevant
medical services. financing of the treatment
process is required.
Depending on the specifics of the current
legislation and existing social relations, different
persons may participate in the medical insurance
contract as the insured. For example, employers
and various social funds are parties to the contract
as insurers in compulsory medical insurance. At
the same time, the citizens themselves are allowed
to be insured in voluntary medical insurance and to
conclude a medical insurance contract.
An insurance organization is an insurance
company that has a license to carry out relevant
activities in the life insurance network and offers
health insurance services. In medical insurance, the
most important aspect of the goal of the insurer's
activity is the implementation of the main principle
"money is spent on the health of patients". Health
insurance means that the insurance company has
an interest in choosing the best doctor and
treatment facility for the patient, and doctors stop
getting paid "per visit" and doctors are now paid
for the services they provide. In cases where there
is no medical insurance, doctors work based on the
system of charging citizens a certain amount of
money for each visit. This is a practice that has been
formed almost all over the world, and the doctor or
the medical institution does not care how much the
citizen benefits or not from such a visit, and does
not take any reasonable and consequential
responsibility for it. It is necessary to recognize
that one of the acceptable ways to end such a
negative and ineffective medical service method
and the negative "pay-per-visit" method is medical
insurance. After all, health insurance guarantees
high-quality medical care and makes it possible to
receive it, and also helps to solve the problem of the
allocation of additional financial resources to the
health sector.
Treatment-prophylactic
institutions,
where
medical services are produced and provided, are
independent entities in the market for the sale of
insurance services, and in the competitive struggle
for the right to enter into contracts with insurance
companies that have paid-up funds of the insured
population, "entrepreneurship" is an organization
that assumes risk. One of the main goals of the
introduction of health insurance is to create a
market environment for the work of health care
institutions, and this, in turn, is to attract additional
funds through insurance by organizations and
residents. allows. At the same time, as a result of
this, the market of medical services will be formed,
and the managers of treatment and prevention
institutions will become sellers of medical services.
World experience shows that the efficiency of the
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use of funds is higher in insurance systems than in
their distribution in the budget system. In market
conditions, the income of healthcare workers
depends on how satisfied the client is with his
medical service and whether he will return to this
address when he needs medical help again. In the
provision of medical services, not only how the
patient is treated, but also how he is treated is
important. The guarantee of the quality of medical
care for the patient is the health insurance
organization, which controls not only the costs, but
also the quality of the medical care.
From the above analysis, it can be concluded that in
order to establish the legal regulatory mechanisms
for the introduction of medical insurance and its
application, it is necessary to create the legal basis
for medical insurance first of all. In this case, it is
necessary to include special articles on medical
insurance in the current Civil Code and define the
most basic rules specific to medical insurance. In
addition, in order to implement medical insurance
on a large scale, it is necessary to adopt the Law "On
Compulsory Medical Insurance" and introduce the
organizational, legal and contractual procedure for
its implementation. The implementation of these
measures, in turn, along with the development of
medical insurance in our country, will lead to the
improvement of the population's health care
system and increase in the quality of stable medical
services.
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