Who will bear the medical expenses not reimbursed by the work-related injury insurance fund?

Lawyers from Tianjin Bozhuan Law Firm, China, is sharing a case for example, to explain who shall be responsible for the additional medical expense which can not reimbursed by work injury fund.

Brief introduction to the case of work injury in China:

The client, Mr. Liu, is an employee of a company. Unfortunately, he suffered from pneumoconiosis due to the nature of his work and the impact of the working environment. The human resources and social security departments determined it to constitute an occupational disease and a work-related injury in accordance with the law. He spent millions of yuan in medical expenses to treat his illness, of which more than half a million yuan was not reimbursed by the work-related injury insurance fund alone due to the complexity and severity of his condition. More than 500,000 yuan is an astronomical figure for the working-class family of Mr. Liu. Mr. Liu spent all his family savings and owed foreign debts to treat his disease. In desperation, Tianjin Bozhuan Law Firm, to handle the rights protection matters. The People’s Court of a certain district in Tianjin supported all the plaintiff Mr. Liu’s claims. The company appealed to an intermediate people’s court in Tianjin. In the end, the intermediate court made a second-instance judgment rejecting the appeal and upholding the original judgment. Recently, the client informed Attorney Wang that all the payment units determined in the judgment have been paid, and expressed great satisfaction with the process and results of the case.

Case analysis of work injury insurance in China:

the trusted lawyer of Tianjin Bozhuan Law Firm believes that according to the third paragraph of Article 30 of the “Regulations on Work-related Injury Insurance”, if the expenses required to treat work-related injuries comply with the work-related injury insurance diagnosis and treatment item catalog, work-related injury insurance drug list, and work-related injury insurance hospitalization service standards, they shall be paid from the work-related injury insurance fund. As for the medical expenses beyond the above categories and standards that are not paid by the work-related injury insurance fund, whether the employer or the work-injured employee shall bear the burden is currently not directly stipulated in laws and regulations. It should be comprehensively based on the legislative spirit of work-related injury insurance, relevant laws, judicial interpretations and legal principles. System considerations.
First, Article 1 of the “Regulations on Work-related Injury Insurance” clarifies the legislative purpose of this law, that is, “in order to ensure that employees who are injured in accidents or suffer from occupational diseases at work receive medical treatment and economic compensation, and promote work-related injury prevention and vocational rehabilitation, decentralize the employer’s “Work-related injury risks, these regulations are formulated.” It can be seen that the primary purpose of the work-related injury insurance system is to promptly treat and compensate workers injured at work. Although the “Work-related Injury Insurance Regulations” do not clearly stipulate how to bear the medical expenses that are not reimbursed by the work-related injury insurance fund, in light of the legislative purpose of the Regulations and considering the objective needs of protecting workers in a vulnerable position and treating work-related injuries, this part of the expenses shall be borne by the employer. The unit burden is more reasonable. In addition, although dispersing the employer’s work-related injury risks through socialized burdens is also an important purpose of the work-related injury insurance system, dispersing risks does not mean that the employer is exempted from all liability for damage compensation. The “Work-related Injury Insurance Regulations” stipulates that the employer should pay its employees The provisions on wages and welfare benefits during the period of layoff and salary leave indicate that the employer should still bear part of the employee’s work-related injury benefits beyond the scope of expenditures of the work-related injury insurance fund. Work-related injury insurance is a system established to ensure that workers who are injured or suffer from occupational diseases due to work can obtain medical treatment and financial compensation, and to disperse the employer’s work-related injury risks; work-related injuries are personal injuries caused by workers due to work, and employers are obliged to protect labor The basic rights of workers, so that workers can have medical treatment and livelihood protection when encountering work-related injuries; the employer pays work-related injury insurance premiums for workers, so that when workers are injured in work-related accidents, they will be paid by the work-related injury insurance fund. The purpose of corresponding work-related injury insurance benefits is to reduce the employer’s operating risks, but not to exempt the employer from legal liability; the medical expenses for the treatment of work-related injuries are paid from the work-related injury insurance fund in accordance with regulations, which does not mean that the employee’s normal work-related injury treatment will , medical expenses that cannot be paid by the work-related injury insurance fund should be borne by the worker personally. It is unfair and contrary to the purpose of legislation to require workers to bear the medical expenses themselves while suffering physical injuries;
Second, Article 59 of the “Law of the People’s Republic of China on the Prevention and Control of Occupational Diseases” stipulates that in addition to being entitled to work-related injury insurance in accordance with the law, patients with occupational diseases who are still entitled to compensation in accordance with relevant civil laws have the right to request compensation from the employer. Article 53 of the “Production Safety Law of the People’s Republic of China” stipulates that employees who are injured due to production safety accidents, in addition to enjoying work-related injury insurance according to law, and still have the right to receive compensation in accordance with relevant civil laws, have the right to file a claim with their unit. Claims for compensation. It can be seen from this that the legislation takes a positive attitude towards workers’ rights to claim civil compensation in addition to work-related injury insurance.
Third, Article 3 of the “Interpretations of the Supreme People’s Court on Several Issues Concerning the Application of Law in the Trial of Personal Injury Compensation Cases” stipulates that if an employee of an employer that is legally required to participate in work-related injury insurance coordination suffers personal injury due to a work-related injury, the employee or his or her immediate If a relative files a lawsuit with the People’s Court and requests the employer to bear civil liability for compensation, the relative shall be informed that the matter shall be handled in accordance with the provisions of the “Regulations on Work-related Injury Insurance”. This clause should be understood as meaning that workers should first claim work-related injury insurance liability for work-related injury compensation. It does not deny that workers have the substantive right to claim compensation from the employer for other losses after enjoying work-related injury insurance benefits.
To sum up, medical expenses beyond the scope of reimbursement by the work-related injury insurance fund should be borne by the employer on a no-fault basis.
In the end, the court of first instance adopted lawyer’s opinion to support the plaintiff Mr. Liu’s claim. After the employer appealed, the court of second instance dismissed the appeal and upheld the original judgment.

Litigation Tips of such case in China

At present, regarding the issue of who should bear the medical expenses that are not reimbursed by the work-related injury insurance fund, the judicial practice of various provinces and cities, in China, has different opinions. After searching the Tianjin Court judgment cases, the current mainstream view in Tianjin judicial practice is that the judgment standard should be borne by the employer. It is recommended that The national departments should formulate unified regulations on the above issues as soon as possible to avoid the phenomenon of different verdicts for the same case across the country.