When you show medical insurance card and receive treatment (保険証を提示して治療を受けるとき)

When you got sick or injured (payment of medical treatment)
病気やケガをしたとき(療養の給付)

When an insured person or a dependent in a health insurance is ill or injured due to an out-of-service reason, a health insurance card (hospital, medical office) should have a health insurance card (if you are 70 years old or older, match an elderly beneficiary card) You can receive medical treatment, such as medical examination, treatment, medication, by filing and paying a part of the contribution. In addition, if you receive a doctor’s prescription, you can have the medicine dispensed at the insurance pharmacy. (This is called “medical treatment benefit.”)

 健康保険の被保険者や被扶養者が業務外の事由により病気やケガをしたときは、保険医療機関(病院・診療所)に保険証(70歳以上の方は高齢受給者証も合わせて提出して下さい。)を提出し、一部負担金を支払うことで、診察・処置・投薬などの治療を受けることができます。また、医師の処方せんを受けた場合は、保険薬局で薬剤の調剤をしてもらうことができます。(このことを「療養の給付」といいます。)

Range of medical treatment benefits
療養の給付の範囲

Doctor’s examination and Inspection:
 If you have a physical problem, you can always take the exams you need for a doctor’s or medical treatment with your health insurance.
Medicine and therapeutic material:
 The medicines necessary for treatment are provided only to those listed at the standard price of the medicine covered by medical insurance.
Treatment and surgery:
 You can receive radiation therapy and medical treatment instruction as well as injection, treatment and surgery.
Hospitalization and nursing:
 For meals and daily life recuperation during hospitalization, a fixed amount will be paid per meal and per day. When you want a special room (such as a private room), it is necessary to bear the difference of the room charge.
Home care and visiting care:
 You can receive home care from a doctor so that you can feel safe and at home. In addition, visiting care can be received by nurses dispatched from a visiting nursing station.
Overseas medical expenses :
 See this website.

診察・検査
 身体に異常があれば、いつでも健康保険で医師の診察や治療に必要な検査が受けられます。
薬・治療材料
 治療に必要な薬は、医療保険の対象となる医薬品の基準価格に掲載されているものに限り支給されます。
処置・手術
 注射や処置・手術はもちろん、放射線療法、療養指導なども受けられます。
入院・看護
 入院中の食事・生活療養については1食・1日につき、決められた額を負担します。特別室(個室など)を希望するときは差額室料の負担が必要です。
在宅療養・訪問看護
 医師が認めた人が安心して在宅で療養できるように、医師による訪問診療が受けられます。また、訪問看護ステーションから派遣された看護師による訪問看護なども受けられます。
海外療養費
 海外療養費の詳細は、こちらをご覧ください。

About medical treatment that can not be received by health insurance
健康保険で受けられない診療について

The medical treatment benefits for health insurance cover the treatment of people who are ill or injured. For this reason, health insurance can not be used for medical treatment (such as cosmetic surgery) received without any problem in daily life. Since pregnancy is not considered a disease, normal pregnancy and delivery are excluded from health insurance coverage. In addition, the benefits may be limited if you have a disease or injury that deviates from the purpose of health insurance.

 健康保険の「療養の給付」は、病気やケガをしたときの治療を対象として行われます。このため、日常生活に何ら支障がないのに受ける診療(美容整形など)に健康保険は使えません。妊娠も病気とはみなされないため、正常な状態での妊娠・出産は健康保険の適用から除外されています。また、健康保険の目的からはずれるような病気やケガをしたときは給付が制限されることがあります。

Cases where health insurance cannot be used
健康保険が使えないケース

  • Plastic surgery for cosmetic purposes
  • Myopic surgery etc
  • Advanced medicine under study
  • Preventive injection
  • Medical check up, Comprehensive medical examination
  • Normal pregnancy and childbirth
  • Abortion due to economic reasons
  • 美容を目的とする整形手術 
  • 近視の手術など
  • 研究中の先進医療
  • 予防注射
  • 健康診断、人間ドック
  • 正常な妊娠・出産
  • 経済的理由による人工妊娠中絶

Exception cases where health insurance can be used
例外的に健康保険が使えるケース

  • If you have trouble with labor due to strabismus etc., you have surgery for birth clefts, plastic surgery for treatment of injuries, surgery for wakiga which causes significant discomfort to others etc..
  • When receiving medical treatment prescribed by the Minister of Health, Labor and Welfare at a university hospital etc.
  • In the case of abnormal delivery due to pregnancy hypertension syndrome (pregnancy toxemia)
  • Artificial abortion to protect the mother when the mother is at risk
  • 斜視等で労務に支障をきたす場合、生まれつきの口唇裂の手術、ケガの処置のための整形手術、他人に著しい不快感を与えるワキガの手術など 
  • 大学病院などで厚生労働大臣の定める診療を受ける場合  
  • 妊娠高血圧症候群(妊娠中毒症)などによる異常分娩の場合
  • 母体に危険が迫った場合に母体を保護するための人工妊娠中絶

Injuries caused by work or commuting disasters?
業務上や通勤災害によるケガは?

Health insurance is not provided for illnesses or injuries caused by work-related or injuries incurred while commuting to work. In principle, workers’ compensation insurance is applied.

 業務上の原因による病気やケガ、通勤途上に被った災害などが原因の病気やケガについては、健康保険給付は行われず、原則として労災保険の適用となります。

Cases where health insurance benefits are limited
こんな場合は健康保険給付が制限されます

About illness or injury in the following cases, you may not be able to receive benefit or may be limited in some cases as it interferes with healthy administration of health insurance system.

  • When a criminal act or intentional accident (illness, injury, death, etc.) occurred
  • When you get sick or injured due to a fight or drunk alcohol
  • When you did not follow the doctor’s (hospital) instructions without justifiable reasons
  • When receiving or trying to receive insurance benefits for swindle or other fraud
  • When you refuse questions or diagnoses instructed by the insurer
  • When you are in a juvenile training school or a penal institution (It is not possible to provide health insurance benefits, however, burial fees and payments to dependents will be provided)

 次のような場合の病気やケガについては、健康保険制度の健全な運営を阻害することになりますので、給付が受けられなかったり、一部を制限されることがあります。

  • 犯罪行為や故意に事故(病気・ケガ・死亡など)を起こしたとき
  • ケンカ、酒酔いなどで病気やケガをしたとき
  • 正当な理由もないのに医師(病院)の指示に従わなかったとき
  • 詐欺、その他不正に保険給付を受けたり、受けようとしたとき
  • 保険者の指示する質問や診断を拒んだとき
  • 少年院や刑事施設などにいるとき(健康保険給付を行うことが事実上不可能なため、支給されません。ただし、埋葬料と被扶養者への支給は行われます)

Published by

Yumiko Kamioka

Yumiko Kamioka

Certified Social Security and Labor consultant, USCPA ||(Website) MASHR Consulting (TEL) 045-594-7315 (FAX) 045-594-7316 (EMAIL) mashr-hr@mashr.co.jp