Medical insurance is the "money for medical treatment" and "money for saving lives" for the public, yet some seek to exploit loopholes by using medical insurance to cover medical expenses while simultaneously suing hospitals for full compensation, attempting to "double profit." Recently, during the trial of a medical malpractice liability case, the Jiangzhou District People's Court in Chongzuo City legally added the Medical Security Bureau as a third party to the litigation, clearly stating: compensation for infringement does not support double profit, and the portion already covered by medical insurance must be directly refunded to the Medical Security Bureau by the infringer!
The plaintiff, Qi, suffered personal injuries due to medical malpractice by a hospital during birth, for which the court had previously ruled the hospital liable for 70% of the damages. From January 2022 to May 2025, Qi incurred subsequent treatment costs totaling 407,889.87 yuan, and based on the liability ratio, the hospital should compensate 285,522.91 yuan. However, during the trial, the court discovered that Qi had already claimed reimbursement of 176,484 yuan for medical expenses through the medical insurance fund during this period. Upon learning this, the Medical Security Bureau (hereinafter referred to as the MSB) voluntarily applied to join the litigation as a third party, requesting the court to order the hospital to refund the aforementioned medical insurance fund within the scope of its liability for compensation.
After trial, the court found that Article 30 of the Social Insurance Law of the People's Republic of China stipulates that medical expenses that should be borne by the infringer are not included in the scope of payment of the basic medical insurance fund. In this case, Qi's medical damage was caused by the hospital's negligence in diagnosis and treatment. As the infringer, the hospital should bear the compensation responsibility for the relevant medical expenses, which should not be borne by the medical insurance fund. Qi illegally reimbursed more than 170000 yuan, causing losses to the national medical insurance fund. The third-party medical insurance bureau has the right to exercise the right of recovery for this portion of the funds in accordance with the law.
Based on this, the court ruled that a certain hospital should compensate Qi with 109038.91 yuan (i.e. the remaining loss after deducting the reimbursed 176484 yuan from the total amount of 285522.91 yuan); At the same time, the hospital must refund the medical security fund of 176484 yuan to the medical insurance bureau within ten days from the effective date of the judgment.
Why can't we take money from both ends?
Violation of the principle of fairness:Infringement compensation only compensates for actual losses and does not allow for additional profits.The core of compensation for infringement damages lies in filling the actual losses of the infringed party, restoring their rights status to before the damage occurred, rather than making them gain additional profits. In this case, if the victim retains the medical insurance reimbursement and claims full compensation from the infringer, it constitutes a "double benefit" that violates the principles of fairness and compensation for losses.
The medical insurance fund is a public interest: the medical insurance fund is the common wealth of all insured persons and cannot "pay" for the faults of infringers.
The law clearly stipulates that medical expenses that should be borne by third parties are not included in the scope of payment of the basic medical insurance fund. The legislative intentionis to protect the public interest and prevent the medical insurance fund from being improperly occupied.
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