Insurance benefits
Health insurance pays various prescribed insurance benefits in the event of nonoccupational sickness or injury, childbirth, and death. The term “insurance benefits” refers to the provision of medical care services and payment for these services.
- Benefits paid for nonoccupational sickness and injury
- In some cases you cannot use health insurance
- System for payment of medical care costs
- Period of eligibility during which insurance benefits may be received
- Description
- FAQ
- POINT
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- Insurance benefits are benefits in cases of nonoccupational sickness or injury.
- Benefits are available only for treatment authorized in advance by the national government (Ministry of Health, Labour and Welfare) as eligible for insurance coverage.
Benefits paid for nonoccupational sickness and injury
If you suffer form a sickness or injury resulting from nonoccupational causes, you can undergo treatment, including the treatments listed below, by showing your health insurance card at the counter of a hospital or clinic that accepts health insurance:
- Medical consultation
- Provision of medicines or therapeutic materials
- Treatment, surgery, or other medical care
- Medical care or nursing care at home
- Hospitalization or nursing care
Use Worker's Accident Compensation Insurance for injuries sustained at work or while commuting
Health insurance provides benefits for nonoccupational sickness or injury. Worker's Accident Compensation Insurance covers injuries sustained at work or while commuting. Note that you cannot receive benefits from both types of insurance for the same injury.
- *When even illnesses and injuries on-the-job are not targeted for benefits of the Worker's Accident Compensation Insurance, benefits of the health insurance are provided except the duties as the officer of the corporation (except for a corporation less than five employees).
Benefits-in-kind and cash benefits
Insurance benefits are provided in two ways: provision of the medical care itself to treat a sickness or injury or provision of funds to cover the cost of medical care. “Benefits-in-kind” refer to the provision of medical care; “cash benefits” refer to the provision of cash to cover medical care costs.
In some cases you cannot use health insurance
Health insurance benefits are available only for treatment authorized in advance by the national government (Ministry of Health, Labour and Welfare) as eligible for insurance coverage as safe and effective treatment methods.
| ✕When you cannot use health insurance | ○When you can use health insurance |
|---|---|
| Freckles, birthmarks, pimples, moles, body odor, and the like that do not obstruct job execution or interfere with everyday life | If you have symptoms that require treatment |
| Nearsightedness, farsightedness, astigmatism and strabismus with no chance of recovery | For medical consultations, checkups, and lens prescriptions by an insurance doctor for a vision abnormality |
| Cosmetic surgery | For cosmetic surgery to treat an injury |
| Health examinations, screenings for lifestyle related diseases, complete check-ups | For treatment deemed necessary following a medical consultation |
| Immunizations and preventive internal medicines | For immunizations against tetanus when the possibility of infection is present |
| Normal pregnancy and delivery | When treatment is needed for pregnancy-induced hypertension, abnormal delivery, or other related conditions |
| Voluntary abortions for economic reasons | For abortion pursuant to the Mother's Body Protection Law for reasons other than economic reasons |
In some cases, insurance benefits are provided subject to certain restrictions
Insurance benefits are restricted in the following cases, even for nonoccupational sickness or injury:
Note that in certain cases, in addition to being required to repay the benefits received, those receiving inappropriate benefits may be subject to criminal prosecution.
| All benefits restricted (not including funeral expenses) |
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|---|---|
| All or some benefits restricted |
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| Some benefits restricted |
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- ** Insurance benefits are not provided to individuals in Juvenile Training Schools, penal institutions, detention facilities, or similar facilities for various reasons, including the availability of alternate medical care benefits at public expenditure (by national or local government).
System for payment of medical care costs
Once you have shown your health insurance card for medical care, the medical care institution bills the Health Insurance Association monthly for the medical care costs covered by insurance. Note that it would be a highly complex undertaking for all medical care institutions and health insurance associations to handle such billing and payment individually.
Accordingly, billing and payment of medical care costs is carried out through healthcare bill check and payment organizations such as the Health Insurance Claims Review & Reimbursement Services (HICRRS). The Health Insurance Association is billed for medical care costs about two months later. Other payments, such as payment of benefits from health insurance to individual members, also takes place at least three months after the month of the medical care.
- Reference link
- Medical care cost information
- Additional benefits
Period of eligibility during which insurance benefits may be received
Apply promptly for insurance benefits.
The period of eligibility during which insurance benefits may be received is two years. For example, after a dependent wife gives birth, she is eligible for benefits such as the Dependents’ Childbirth and Childcare Lump-Sum Grant, but this eligibility lapses two years and you will lose the right to receive them after two years if you fail to apply for these benefits. Keep this period in mind while you are eligible for benefits.
Details of the period of eligibility during which insurance benefits may be received are shown below. You will no longer be eligible to receive the benefit after the date shown below.
| 1 | Injury and Sickness Allowance, Maternity Allowance: two years from the day after each date on which you became unable to work |
|---|---|
| 2 | Childbirth and Childcare Lump-Sum Grant, Dependents’ Childbirth and Childcare Lump-Sum Grant: two years from the day after the date of childbirth |
| 3 | Funeral Expenses, Dependents’ Funeral Expenses: two years from the day after the date of death |
| 4 | Medical care expenses: two years from the day after the date the patient paid the expenses |
| 5 | High-Cost Medical Care Benefits: two years from the first day of the month after the month of the medical care (or the day after the date of payment of your copayment for medical care costs if you paid in the following month or later) |
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