我国医疗责任强制保险制度研究(硕士)

我国医疗责任强制保险制度研究(硕士)(论文150000字)
摘要：医疗纠纷将会导致医患关系紧张等社会秩序遭到破坏的结果。我国当前处理医疗纠纷的主要手段仍然是事后的诉讼制度，根据域外经验，医疗责任强制保险更具有效果，实现该制度的本土化具有学术价值、应用价值和社会意义。学术价值层面，强制医疗保险制度强调本土特色、理论生命旺盛、促成学科交叉与综合运用；应用价值层面，强制医疗保险制度符合时代背景、推动立法完善；社会意义层面，强制医疗保险制度促成社会共识、制度性监督医疗机构。基于此，为了完善侵权责任法的风险分散理论、助力医疗卫生体制改革与发展、使医患纠纷的解决出现新思路、在实践中给患者权益的维护和保障提供理论支撑、分散医务人员及医疗机构的执业风险，本文基于广义的、《侵权责任法》中的定义，以保险制度中的责任为核心，广泛意义上理解不只作为民事责任的医疗责任，在此概念基础上以我国医疗责任强制保险制度研究为主题展开研究。
我国医疗责任保险制度以在国家产品化及政策性文件和在各地以制度性探索的形式展开，具有多个层面的问题：医疗机构持观望态度，仍然采取传统的纠纷处理方式；保险公司持谨慎态度，医疗责任保险运营状况困难；患者存在误解。本质上讲，造成上述问题的原因有：思想认识落后、规则体系混乱、强制效力缺乏、操作过程僵化、智力支撑不足。构建医疗责任强制保险制度应当首先奠定理论基础，经济学角度提供了福利经济思维，认为医疗责任强制保险制度是使得整个社会的福利总量进行扩增的“放大器”、对社会福利总量进行个体化最佳分配的“协调器”、对社会福利进行政府干预、防止其出现失衡的“稳定器”；法学基础理论认为，医疗责任强制保险是对公民健康权的保障，这在国际条约、宪法和民法中均有体现；当前社会是一个风险社会，诊疗活动风险是医患纠纷解决的重要内容，风险分散理论能够使风险承担主体增多、压力承担面扩大，从而为医疗责任强制保险制度设定理论基础。在我国，该制度建立的现实基础应当透过医患关系来分析，我国当前医患关系日益恶化，从经济学的角度看，其本质是人民群众日益增长的医疗服务需求同仍不完善的医疗服务市场之间的矛盾；从社会学的角度看，医生具有单向主导性，患者缺乏对信息的知情以及信息的知情；从伦理学的角度看，医患关系具有多元的、双向的伦理影响；同时，医务人员的疏忽或盲目自信造成误诊、医务工作者能力不足等也是造成现实医患关系紧张的原因。医疗责任强制保险制度能够保障患者权益、缓解医疗机构以及医务工作人员的压力、促使医患矛盾得到缓解。作为本土化分析的对象，医疗责任保险制度具有与交强险相似的性质与制度设计，在我国更具有观念上的可接受性。医疗责任强制保险具有社会性，能够解决社会矛盾、照顾弱势群体；具有功能性，能够重建医疗信任、缓解医患矛盾，有效弥补医疗损害，优化医疗资源配置；具有价值性，需要在效率、公平以及秩序之间进行选择。

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医疗责任强制保险制度的建立应展开立法化，因此应首先明确法律关系。投保人为医疗机构，具有解除合同的权利和按时缴纳保险金、如实告知的义务；被保险人为医疗机构或医务人员，但应当排除医生、受委派的医师以及实习生，具有指定受益人的权利，也承担着告知真实情况的义务；承保主体是保险公司，具有请求被保险人缴纳保险费、要求投保人和保险人如实告知、对被保险人进行一定的监督的权利，同时也具有说明保险内容、提示保险内容的义务。其次应当对保险利益进行分析。保险利益的责任基础应当基于不同情况区分过错责任、无过错责任和公平责任，最终补偿效果归属于受损害人，保费由医疗机构进行承担，赔偿额度问题实际上是侵权责任问题，应区分人身损害赔偿和精神损害赔偿，具体设计为直接赔偿和间接赔偿，积极的精神损害赔偿和消极的精神损害赔偿。在承包范围的设计上应当区分以下几个重点问题，医疗责任强制保险应当排除医疗故意引起的损害赔偿，医疗过失引起的损害赔偿不应当被排除，医疗意外引起的损害赔偿应当纳入承包范围。医疗责任强制保险的免责事由既应当包括侵权责任法的免责事由、也应当包含保险法的免责事由，同时也应当具有本部门法律的特性，即要考量利益平衡的问题，免责事由是对各方利益的重新平衡，根据日本、台湾地区的经验，结合本土语境，免责事由的一般条款应当划分为原因免责，情形免责，特定的损失、费用和责任；在具体实践中存在就医务人员不符合治疗资质的免责，就医务人员使用的不符合标准的医疗器材、药品等免责，对于不在诊疗目的下进行的医疗活动免责，对于意料意外的免责。基于以上探讨，我国医疗责任强制保险的免责事由应当区分为医疗过失责任保险免责事由和医疗意外责任保险免责事由，前者包括被保险人或其医务人员的故意行为和非执业行为等，后者包括各类医疗意外事件引发的责任。除了以上传统保险责任的法律制度设计之外，相关配套制度和机制也应当进行完善：其一，应当构建一元化的医疗损害鉴定制度，实现统一性；建立医疗纠纷ADR的解决方式，促成纠纷在诉讼之外的真正解决；加强医疗纠纷调解队伍的建设，建立保险公司内部的医疗责任保险处理组织或机构，建立专家库等；此外，医疗风险及保险大数据库的建立和医疗责任保险基金及互助组织的建立均是时代背景下新的配套方案；整体制度设计之外，也应当强化对医疗责任强制保险的监管。

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图X幅，表X个，参考文献X篇

关键词：医疗责任保险；医患矛盾；风险分散理论；利益平衡原则
分类号：

STUDY ON COMPULSORY INSURANCE SYSTEM OF MEDICAL LIABILITY IN CHINA
Abstract: Medical disputes will result in the disruption of social order, such as the tension between doctors and patients. The main means of dealing with medical disputes in our country is still the lawsuit system after the event, according to the extraterritorial experience, the medical liability compulsory insurance has more effect, and it has academic value, applied value and social significance to realize the localization of the system. The academic value level, the compulsory medical insurance system emphasizes the native characteristic, the theory life exuberant, promotes the interdisciplinary and the comprehensive application of the discipline, the application value level, the compulsory medical insurance system conforms to the time background, promotes the legislation consummation; Based on this, in order to perfect the tort liability law's risk dispersion theory, to help the reform and development of medical and health care, to bring about new ideas for the settlement of medical disputes, to provide theoretical support for the maintenance and guarantee of patients ' rights and interests, to disperse the practice risks of medical personnel and medical institutions, this article is based on the definition in the broad sense, the law of tort liability Taking the responsibility in the insurance system as the core and understanding the medical liability in a broad sense not only as civil liability, on the basis of this concept, the research on the compulsory insurance system of medical liability in our country is studied as the theme.

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China's medical liability insurance system in the national product and policy documents and in the form of institutional exploration, there are many aspects of the problem: the medical institutions hold a wait-and-see attitude, still take the traditional way of dealing with the dispute, insurance companies cautious, medical liability insurance operating conditions difficult; In essence, the causes of the above problems are as follows: The thought is backward, the rule system is confused, the force is short, the operation process is rigid, and the intelligence support is insufficient. The construction of medical liability compulsory insurance system should first lay the theoretical foundation, the economics angle provides the welfare economic thinking, thinks that the medical liability compulsory insurance system is the "amplifier" which makes the whole social welfare total increase, the "coordinator" of the individual optimal distribution of the total social welfare, and the government intervention to the social welfare, The "stabilizer" that prevents it from appearing unbalanced; the basic theory of law holds that medical liability compulsory insurance is the guarantee of citizens ' right to health, which is embodied in international treaties, constitutions and civil law. At present, society is a risk society, the risk of diagnosis and treatment is the important content of the dispute resolution, and the risk spreading theory can make the subject of risk increased The pressure bearing face expands, thus establishes the theory Foundation for the medical liability compulsory insurance system. In our country, the realistic foundation of the system should be analyzed through the relationship between doctors and patients, at present, the relationship between doctors and patients is deteriorating, from the angle of economics, its essence is the contradiction between the people's increasing demand for medical service and the still imperfect medical service market. From a sociological point of view, the Doctor has a one-way lead, Patients lack of information and information, from the perspective of ethics, doctor-patient relationship has a pluralistic, two-way ethical impact, at the same time, the negligence or blind self-confidence of medical staff caused misdiagnosis, medical workers lack of ability, etc. is also caused by the real relationship between doctors and patients tension. The medical liability compulsory insurance system can guarantee the patients ' rights and interests, relieve the pressure of the medical institutions and medical staff, and make the doctor-patient contradiction relieved. As the object of the localization analysis, the medical liability insurance system has the similar nature and the system design with the strong risk, and has the concept acceptability in our country. Medical liability compulsory insurance has sociality, can solve social contradictions, take care of disadvantaged groups, has function, can reconstruct medical trust, relieve doctor-patient contradiction, effectively make up medical damage and optimize medical resource allocation; It is valuable to choose between efficiency, fairness and order.

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The establishment of medical liability compulsory insurance system should be legislated, so the legal relationship should be defined first. The insured is a medical institution, having the right to terminate the contract and the obligation to pay the insurance money on time and to truthfully inform; The insured shall be a medical institution or medical officer, but the physician, the appointed physician and the trainee, with the right to designate the beneficiary, and the obligation to inform the truth, should be excluded; It has the right to ask the insured to pay the insurance premiums, to require the insured and the insurer to give truthful notice to the insured, and also to have the obligation to explain the content of the insurance and the content of the insurance. Secondly, the insurance interests should be analyzed. The liability basis of insurable interest should be based on different circumstances to distinguish fault liability, without fault liability and fair liability, the ultimate compensation effect belongs to the injured person, the premium is borne by the medical institution, the compensation limit is actually the tort liability problem, which should distinguish the personal injury compensation and the mental damage compensation, specifically designed for direct compensation and indirect compensation, Positive mental damage compensation and negative mental damages. The design of contract scope should be divided into the following key issues, medical liability compulsory insurance should exclude medical intentional damage compensation, medical negligence caused damage compensation should not be excluded, medical accident caused damages should be included in the scope of the contract. The exemption of medical liability compulsory insurance should include the exemption cause of tort liability law, should also contain the exemption cause of insurance law, but also should have the characteristics of the department's laws, that is, to consider the issue of balance of interests, the exemption is to balance the interests of all parties, according to the experience of Japan, Taiwan, combined with the local context, The general clause of the exemption cause shall be divided into the reason exemption, circumstances, specific losses, costs and liabilities; in the practice of the medical personnel in the absence of compliance with the treatment of the exemption, in respect of medical personnel used substandard medical equipment, drugs and other exemptions, for not the medical activities carried out under the exemption, An exemption from unexpected surprises. Based on the above discussion, the exemption of medical liability compulsory insurance should be divided into the exemption cause of medical negligence liability insurance and medical accident liability insurance, the former includes intentional behavior and non practice of the insured or its medical personnel, the latter includes the responsibility of all kinds of medical accidents. In addition to the legal system design of traditional insurance liability, relevant supporting system and mechanism should also be perfected: firstly, we should construct the unified medical damage appraisal system, realize the unification, establish the solution way of ADR of medical dispute, promote the real solution of the dispute outside the lawsuit, and strengthen the construction of the mediation team of medical dispute, To establish a medical liability insurance treatment Organization or institution within an insurance company, establishment of expert database and so on; In addition, the establishment of medical risk and insurance databases and the establishment of medical liability insurance funds and mutual aid organizations are the new supporting schemes under the background of the Times, and the supervision of compulsory medical liability insurance should be strengthened in addition to the overall system design.

Keywords: medical liability compulsory insurance, doctor-patient contradiction, risk dispersion theory, interest balance principle
Classification:
 
目  录
第1章绪论    1
1.1问题的提出    1
1.2研究意义与目的    1
1.2.1  研究意义    1
1.2.2  研究目的    4
1.3  研究现状    8
1.3.1  域外对医疗责任保险实行强制之后的效用的研究    9
1.3.2  关于我国医疗责任保险制度建构与发展现状的研究    12
1.3.3  医疗责任保险制度的建立和意义研究    14
1.3.4  是否应当构建强制性医疗责任保险制度的研究    15
1.3.5  医疗责任保险制度中的法律关系研究    15
1.3.6我国部分省市医疗责任强制保险试点的实效研究    16
1.4研究思路、方法和研究内容    17
1.4.1研究思路    17

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1.4.2研究方法    19
1.4.3研究内容    20
1.5相关概念界定    21
1.5.1医疗的定义    21
1.5.2责任的定义    22
1.5.3医疗责任的定义    23
1.5.4保险的定义    24
1.5.5医疗保险与医疗责任保险的区分    25
第2章我国医疗责任保险的制度困境与成因    27
2.1我国医疗责任保险制度现状描述    27
2.1.1  国家层面的推进    27
2.1.2地方层面的探索    28
2.2我国医疗责任保险制度的发展困境    28
2.2.1  医疗机构的观望    28
2.2.2保险公司的谨慎    29
2.2.3  患者的误解    30
2.3我国医疗责任保险制度陷入困境的成因    30
2.3.1思想认识滞后    30
2.3.2规则体系混乱    31
2.3.3强制效力缺乏    31
2.3.4操作过程僵化    32
2.3.5智力支撑不足    33
2.4小结    33
第3章医疗责任强制保险制度建构的理论逻辑与现实背景    35
3.1医疗责任强制保险制度的理论基础    35
3.1.1实行医疗责任强制保险的经济学动因    35
3.1.2医疗责任强制保险对健康权的保障    40
3.1.3医疗行为的风险性与风险分散理论    44
3.2我国建立医疗责任强制保险的现实背景：以医患关系为中心    48
3.2.1我国当前日益恶化的医患关系及其实质    49
3.2.2医疗责任强制保险对医患关系的缓解作用    54
3.3观念上的可接受性：与交强险的比较    56
3.4小结    61
第4章医疗责任强制保险制度的定性、功能和价值选择    64
4.1医疗责任强制保险的社会性    64
4.1.1社会性的概念辨析    64
4.1.2医疗责任强制保险社会性的体现    65
4.2医疗责任强制保险制度的功能    66

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4.2.1重建医疗信任，缓解医患矛盾    66
4.2.2有效弥补医疗损害    67
4.2.3优化医疗资源配置    68
4.3价值选择    69
4.3.1效率价值    69
4.3.2第三方介入带来的公平性    69
4.3.3个人自由与公共秩序的共同实现    70
4.4小结    71
第5章医疗责任强制保险制度中的法律关系    72
5.1投保人、被保险人与承保主体    73
5.1.1医疗责任强制保险制度中的投保人    74
5.1.2医疗责任强制保险制度中的被保险人    77
5.1.3医疗责任强制保险制度中的承保主体    80
5.2医疗责任强制保险的保险利益    84
5.2.1保险利益的责任基础    84
5.2.2保险利益的归属主体    86
5.3医疗责任强制保险的保费承担    87
5.3.1保费的承担主体    87
5.3.2保费的确定依据    88 [资料来源：www.doc163.com]
5.4医疗责任强制保险的赔偿额度    90
5.4.1赔偿额度的决定因素    90
5.4.2赔偿额度的具体设计    92
5.5小结    93
第6章医疗责任强制保险的承保范围    95
6.1我国医疗责任保险承保范围的现状    95
6.2我国医疗责任强制保险承保范围的确定    95
6.2.1医疗故意引起的损害赔偿不应承保    96
6.2.2医疗过失引起的损害赔偿应当承保    99
6.2.3医疗意外引起的损害赔偿应纳入承保范围    102
6.3小结    106
第7章医疗责任强制保险的免责事由    108
7.1免责事由概述    108
7.1.1免责事由    108
7.1.2免责事由的类型    109
7.1.3保险合同免责事由    109
7.1.4我国医疗责任免责事由的立法模式    110
7.2免责事由：医疗责任强制保险的利益平衡    111
7.2.1医疗责任强制保险可能带来的利益失衡问题    111
7.2.2免责事由是对各方利益的重新平衡    112
7.2.3医疗责任保险免责事由的明确说明    113
7.3域外医疗责任保险免责事由的相关规定    114
7.3.1日本医疗责任保险免责事由    114
7.3.2我国台湾地区医疗责任保险免责事由    115
7.4我国医疗责任强制保险免责事由的具体设计    116
7.4.1免责事由的一般条款    117
7.4.2实践中我国的医疗责任保险免责事由    120
7.4.3免责事由的具体设计    123
7.5小结    124
第8章相关配套制度和机制的完善    126
8.1医疗损害鉴定制度的一元化构建    126
8.1.1当前二元对立的医疗损害鉴定制度    126
8.1.2一元化医疗损害鉴定制度的优势    128
8.1.3一元化医疗损害鉴定制度的构建路径    131
8.2建立医疗纠纷ADR解决    136
8.2.1ADR的主要类型    137
8.2.2医疗责任保险中ADR的建构    139
8.3配套机构的建设和完善    141
8.4医疗风险及保险大数据库的建立    142
8.5医疗责任保险基金及互助组织建立    144
8.6强化对医疗责任强制保险的监管    145
8.6.1美国医疗危机带来的保险监管启示    146
8.6.2构建有力的医疗责任强制保险监管机制    146
8.7小结    148
第9章结语    149
参考文献    154
附录：医疗责任强制保险条例（主要条款建议稿）    155