Benefits paid for nonoccupational sickness and injury

If you suffer from a nonoccupational sickness or injury, you can undergo treatment, including the following, at a hospital or clinic providing medical care covered by 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 and provision of money 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.

Payment methods for cash benefits

The Association pays cash benefits in the following ways:

• Cash benefits on amounts paid at medical care institutions (e.g., High-Cost Medical Care Benefits, Patient Cost-Sharing Reimbursements, and Additional Benefits)
  
  The Association pays cash benefits on high copayment amounts paid at medical care institutions by the following method in order to reduce application burden on members:
  The amount reimbursed is calculated automatically based on the invoice for medical care costs sent from the medical care institution to the Association and paid through your employer.
  (You will be sent an Insurance Benefits Decision/Payment Notice by in-house mail, before the payment date, after the benefit details have been determined.)

  Payment date	Paid through salary 3 months after the month of medical treatment * For retired employees, it will be paid to a personal account on the last day of 3 months after the medical treatment month. If the health insurance association needs to confirm your account, we will send you a "Transfer account application form" so please be sure to return it. *Note that payment may be delayed if the invoice sent from the medical care institution to the Association is delayed.
  Notice sent	Sent by post to your home address
  Paid to	Your payroll account　* Personal account for retired employees

• When the insured and dependents who are members of the association give birth using the direct payment system
  
  We will confirm the fact of childbirth based on the “(Family) Childbirth and Childcare Lump-sum Grant“ request from the medical institution to our association, and will pay you 90,000 yen as “(Family) Childbirth and Childcare Additional Sum“.
  If the cost of childbirth is less than the legally paid amount of 420,000 yen (408,000 yen for medical institutions that do not have an obstetric medical insurance system), the difference will be paid.
  

  Payment date	Paid through salary 3 months after the month of medical treatment * For retired employees, it will be paid to a personal account on the last day of 3 months after the medical treatment month. If the health insurance association needs to confirm your account, we will send you a "Transfer account application form" so please be sure to return it. *Note that payment may be delayed if the invoice sent from the medical care institution to the Association is delayed.
  Notice sent	Sent by post to your home address
  Paid to	Your payroll account 　* Personal account for retired employees

• 「Injury and Sickness Allowance」「Maternity Allowance」
  
  If a reason for application occurs, the insured person should prepare and submit the application form and necessary documents.
  

  Payment date	Applications that arrive at the Health Insurance Association by the 15th of every month are paid on the last day of the month * Depending on the content of the application, it may take some time before the payment date due to inquiries to related parties.
  Notice sent	Mailed to the insured address stated on the application form
  Paid to	Transfer account stated in the application form (limited to those in the name of the insured in principle)

• Cash benefits other than (1.2.3.)
  
  If a reason for application occurs, the insured person should prepare and submit the application form and necessary documents.
  

  Payment date	Applications that arrive at the health insurance association by the 15th of every month will be paid through the salary of the following month * For retired employees, it will be paid to a personal account on the last day of 3 months after the medical treatment month * Depending on the content of the application, it may take some time before the payment date due to inquiries to related parties.
  Notice sent	Mailed to the insured address stated on the application form
  Paid to	Your payroll account 　* Personal account for retired employees

In some cases you cannot use health insurance

Health insurance benefits are available only for treatment authorized in advance by the national government as eligible for insurance coverage as safe and effective treatment methods.

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:

• ** Insurance benefits also 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.