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团体短期健康险理赔项目风险管理研究——以Z寿险公司理赔项目为例
引用本文:张懿.团体短期健康险理赔项目风险管理研究——以Z寿险公司理赔项目为例[J].安徽农业大学学报(社会科学版),2014(4):55-61.
作者姓名:张懿
作者单位:安徽国际商务职业学院 财会金融系
摘    要:我国人身保险市场存在各类理赔风险隐患。以Z寿险公司承保的安徽阳光粮油食品进出口公司团体短期健康险理赔项目为例,采用德尔菲法建立风险评价的指标体系,运用模糊综合评价法建立Z寿险公司团体短期健康险理赔项目风险评价模型,对该项目进行风险识别和评价,得出该项目风险整体风险评价为“中”,对评价结果分析后发现,来自投保人以及医疗机构等利益相关者的道德风险较高,且该险种销售业绩低迷影响理赔服务质量是造成项目风险的主要原因。驻医疗机构理赔代表制、就诊费用审查制、定点医院管理等措施可以有效控制风险。

关 键 词:短期健康险  项目管理  风险管理  保险理赔

Risk Management of Group Short-term Health Insurance Claim:A Case Study of Z Insurance Company
ZHANG Yi.Risk Management of Group Short-term Health Insurance Claim:A Case Study of Z Insurance Company[J].Journal of Anhui Agricultural University(Philosophy & Social Sciences Edition),2014(4):55-61.
Authors:ZHANG Yi
Institution:Department of Accounting and Finance, Anhui Institute of International Business
Abstract:There exist all kinds of claim risks in China' s life insurance market. Taking the group short-term health insurance claims of Anhui Sunshine Cereals, Oils and Foodstuffs Import and Export Company underwritten by Z Life Insurance Company as an example, using the Delphi method and adopting the fuzzy comprehensive evaluation method, the study establishes a risk evaluation index system to set up a project risk evaluation model for the group short-term health insurance claims of Z Life Insurance Company. It is concluded that the project' s overall risk is at medium level, since the moral risk of the applicant, the medical institutions and other stakeholders is high, and the unsatisfactory sales performance of the project has affected the quality of claim service. Some solutions for controlling the risks are put forward.
Keywords:short-term health insurance  project management  risk management  insurance claims
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