Medical insurance in Russia differs from foreign counterparts. Every Russian, regardless of age, income, health status, has a policy compulsory insurance(OMS), which means that he can receive medical assistance anywhere in the country. Why, then, is VHI needed and what does it include?

According to the Constitution, every citizen Russian Federation has the right to free medical care and medical assistance. With only one caveat - the list medical services on compulsory medical insurance is rather limited. Need to expand the list of services? Get them faster? Should I pay less for emergency examinations or get a free specialist consultation without waiting in line? The voluntary health insurance (VHI) service has been developed for this very purpose.

What is included in the standard VHI?

Distinguish between standard VHI policy and a policy with additional insurance programs. The standard policy usually provides:

• outpatient and polyclinic service;
• basic dentistry (X-ray, filling, root canal treatment);
• basic examinations and procedures;
• hospitalization;
• provision of medicines throughout its entire length;
• ambulance;
• calling a doctor at home.

Additionally, by paying an increased insurance premium, the insured can expand the list of voluntary health insurance services. This could be:

• pregnancy and childbirth (including ultrasound, gynecologist, etc.);
• protection and treatment against tick bites;
• medical care abroad;
• extended dentistry, such as prosthetics;
• personal doctor services;
• spa treatment and much more.

What are the offered services and why cannot they be obtained under the CHI? Outpatient and polyclinic service implies the assignment of the insured to one of the polyclinics with which the insurance company works. The client can receive advice and treatment from specialized specialists without waiting in line, as well as count on basic diagnostic tests and physiotherapy. More expensive examinations, such as MRI and CT, are not provided under the standard VHI policy.

Each insurance company independently decides how complete the list of services included in the standard VHI policy will be. The table below provides examples of VHI programs. offered by the leaders of the insurance market.

Insurance company name	Services included in the standard VHI policy
Rosgosstrakh	Outpatient and polyclinic care; Dental care; Ambulance and emergency medical care; Emergency inpatient treatment.
Sogaz	Outpatient and polyclinic service; Emergency; Dental care; Emergency and planned inpatient services; Consultative and diagnostic assistance.
RESO-Garantia	Outpatient care; Home help; Ambulance.
ZHASO	Inspection, consultation; Diagnostics; Outpatient service; Dental services (filling, cost of materials, surgery and prosthetics); Emergency home help; Vaccination.

What is included in the extended VHI?

The following programs may also be included as additional services that expand the scope of insurance coverage of a standard VHI policy:

• Pregnancy management is a separate policy with an impressive list of procedures, examinations and measures, which the insured person (pregnant) forms independently, depending on their financial capabilities and desires. This is one of the most expensive additional VHI programs;
• Treatment and protection against a tick bite is especially necessary in the spring-summer-autumn period, when cases of infection with encephalitis and borreliosis (aka Lyme disease) are common. When issuing such a policy insurance organization guarantees a diagnostic examination of the patient and the tick, inpatient care, resuscitation measures according to indications, drug treatment, prophylaxis and physiotherapy;
• VHI policy for tourists will help you not to be left without medical support on short-term trips abroad. In fact, this is VHI under the standard health insurance program, only abroad;
• Extended dentistry - will allow to include prosthetics and surgical intervention in the policy;
• Personal doctor - for those who want to be consulted and treated by the same specialist who knows well the peculiarities of the health of the insured person;
• Sanatorium treatment - will provide an opportunity to receive rehabilitation and recovery services in sanatoriums that have entered into an agreement with the selected insurance company.

Any type of health insurance has its drawbacks. In the case of VHI, the insured may be denied medical care under the policy if he suffers from: oncological diseases, mental disorders, diabetes, tuberculosis, renal and hepatic insufficiency, hepatitis of any type, sexually transmitted diseases and occupational diseases. The client will also be denied insurance services if illegal or malicious acts, suicidal acts or the consequences of alcohol, drug or toxic intoxication are seen in his illness or injury.

In the line of individual VHI programs, you can choose both the simplest one, which covers only polyclinic services, and a comprehensive program, which includes consultations with a personal doctor and pharmacy services.
Within each health insurance product, the cost will depend on the chosen network of clinics - from inexpensive to VIP. In addition, the price is influenced by the age of the person and the information specified in the questionnaire.

The main list of VHI products for individuals:

1. Base. Provides only polyclinic services, including home help. Price from 37,700 rubles.
2. Standard. Covers polyclinic and dental services. Cost from 48,200 rubles.
3. Optimal. Includes outpatient and dental treatment, as well as emergency inpatient care. Cost from 59 900 rubles.
4. Premium. Includes polyclinic and dental services, emergency inpatient care, pharmacy services. Price from 64,700 rubles.
5. Platinum Maximum coverage: polyclinic and dental services, emergency inpatient care, pharmacy services, personal doctor services. Cost from 71,700 rubles.

Clinic networks on the map

Every parent worries about the health of their child. Many of them had to make difficult choices regarding the search for a doctor who is able to become an ally and like-minded person in the process of raising a healthy person. We suggest that you choose the optimal voluntary health insurance program for which you can get the necessary medical advice and assistance.

By analogy with individual VHI programs for adults, you can buy both the simplest one, which covers only polyclinic services, and a comprehensive program, including the supervision of a personal doctor and pharmacy services.
How much does VHI cost? Within each product, the cost depends on the chosen network of clinics - from inexpensive to VIP. In addition, the cost is influenced by the age of the child and the data of the questionnaire.

1. Base. Provides only polyclinic treatment, including home help. Cost from 47 400 rubles.
2. Standard. Includes outpatient and dental services. Cost from 57,500 rubles.
3. Optimal. Covers outpatient and dental care, emergency inpatient care. Cost from 67 100 rubles.
4. Premium. This includes outpatient and dental services, emergency inpatient care, and pharmacy services. Cost from 71,200 rubles.
5. Platinum Provides maximum coverage: outpatient and dental services, emergency inpatient care, pharmacy services, personal doctor services. Cost from 83,700 rubles.

Clinic networks on the map
Child life insurance

During pregnancy, the last thing you want to worry about is visiting a doctor. VHI insurance will allow you to receive high-quality medical care in connection with pregnancy and childbirth in the clinic of your choice.

1. Pregnancy management from 1 trimester or later - from 100,057 rubles.
2. Obstetrics - from 77 940 rubles.

You can choose from the following medical institutions:

• City Clinical Hospital No. 64;
• Scientific Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov;
• GKB No. 1 named after N.I. Pirogova;
• City Clinical Hospital No. 29 named after N.E.Bauman;
• City Clinical Hospital No. 67 named after L.A. Vorokhobova;
• GKB named after A.K. Eramishantsev;
• JSC "K 31 City".

Refusals of emergency hospitalization under VHI are not common, but each of them can be fatal

Photo: inhabitant / Depositphotos.com

There are situations when delay is literally like death - when a person needs emergency hospitalization or emergency medical care. However, sometimes insurance companies refuse such assistance. Banks.ru found out on what grounds the insurer can do this.

"You will die, but no one will pay attention to you"

For the sake of fairness, I would like to note that there are very few complaints about such refusals in the "People's rating" of Banki.ru. The most common form of "refusal" is latent, that is, delaying with the answer that in certain cases (heart attack, stroke, sepsis, hypoglycemic coma, exacerbation of cholelithiasis, etc.) can be fatal.

“They don't answer calls for hours. They do not send SMS on time or send without the name of the medical institution. They deliberately distort your official health complaints in letters so as not to pay your expenses, ”says an insured person at AlfaStrakhovanie-OMS from St. Petersburg and adds:“ You will die, but no one will pay attention to you or show you sympathy for you. This company has such a terrible Solitar Groups assistance. There would be no price for him in the camps of mass destruction - Buchenwald and Auschwitz. "

Where you took the policy, complain there

A client of IC VTB Medicine from Komsomolsk-on-Amur complains that he was denied emergency hospitalization and treatment for a stroke on the basis that the policy was ... invalid. “I called the support service on Saturday, they told me to call on Monday, I can’t help<…>How to live then? And if I hadn't borrowed money, would I have died because of you? Because of your policy? " - he wrote on the website ( copyright spelling and punctuation preserved). In this situation, the insurance company acted legally, albeit inhumanely. In order not to get into a situation where you seem to be entitled to treatment, but you have to pay for it yourself, you should, having received a VHI policy, call medical panel company and check if you have valid insurance. In this story, the insured should, after removing the acute health situation, contact the insurance company and find out how the policy could be invalid. If there was a mistake by the insurer, he will be obliged to reimburse the cost of treatment. The cost will most likely have to be verified by checks.

It is necessary to clarify that, no matter how "advanced" and expensive your VHI policy is, it is better to have insurance in the form of compulsory medical insurance.

Emergency medical care in our country is free - it was, is and, according to the assurances of all those involved, will always be.

Bring to the diagnosis

The insurer has the right to refuse emergency hospitalization, for example, if it is not included in insurance coverage at all. But there are not very many such programs on the market.

“In the practice of our insurance company, there are practically no refusals from emergency hospitalization. Perhaps, if only the insured does not have such an option in the program at all, ”says Alexander Lapunov, director of the underwriting and voluntary health insurance department of AlfaStrakhovanie. - The need for emergency hospitalization arises when the life of the insured is threatened, and at this stage it is still impossible to say exactly what kind of disease caused such a threat. After stopping the emergency and clarifying the diagnosis, we make a decision on further treatment. "

Emergency and urgent medical care must be provided by a medical institution without fail regardless of the form of ownership, SOGAZ specialists emphasize. “In the absence of emergency hospitalization in the VHI program (this option is usually included in SOGAZ programs) or in the case of a request for emergency hospitalization for a“ non-insured ”diagnosis that is not included in voluntary medical insurance program, such assistance is organized by the municipal ambulance service, ”the company explained to Banki.ru. What exactly is included in the insurance coverage is spelled out in the corresponding document - “Voluntary health insurance program” or in a special memo to the insured. It is necessary to study this document before contacting a medical facility or insurance company.

"A plague on both your houses"

What can become a "non-insurance" diagnosis, Banki.ru asked several leading insurers. Can a suspicion of a previously undiagnosed disease (when a diagnosis is required in an acute condition) be a reason for refusal:

Heart attack or pre-infarction condition;

Stroke;

Oncology;

Benign tumors;

Hepatitis;

Diabetes;

Acute cholecystitis, etc.?

The experts explained that in acute conditions, the insurer, as a rule, provides emergency assistance up to hospitalization and "leads" the client until the diagnosis is delivered. And only then he decides what to do with it next.

According to Tatiana Kaigorodova, Deputy General Director of Ingosstrakh, the vast majority of these diseases fall under the VHI program and are treated within its framework. “As a rule, even if an illness requiring emergency hospitalization is an exception to the VHI program, we do not deny the client emergency medical care and emergency hospitalization,” comments Kaigorodova. “And only then, when emergency assistance is provided, if the disease is not an insured event, the patient is transferred to the compulsory medical insurance service or to a quota.”

As a rule, VHI programs on the market are not included in the programs for diseases, when diagnosed, there are state programs for medical care and treatment. These are diseases such as AIDS and its complications, tuberculosis, especially dangerous infections (plague, cholera), mental illness, etc. At the same time, many VHI programs, in particular, SOGAZ, include diagnostics of such diseases. “The liability of the insurer under the VHI program is valid until a diagnosis is made that is not included in the insurance coverage under its terms,” explains SOGAZ. - If such a diagnosis is established, it is possible to transfer the insured to treatment under the compulsory medical insurance policy or for cash. In this case, the insurer can develop an individual program of treatment for the insured, additionally paid by the insured, taking into account the clinical picture of his condition. "

The presence of an insured person with a disease that is not included in the VHI program does not in any way infringe upon his rights when treating other diseases in full, recalls Alexander Lapunov from AlfaStrakhovanie.

However, there are cases when both emergency and even planned hospitalization are included in the program, and there is no diagnosis yet, and the insurer still refuses urgent hospitalization when a doctor turns up, who finds that a patient has critical, from his point of view, indicators. For example, a Muscovite insured under the corporate VHI program at Renaissance Insurance, for whom an endocrinologist required urgent hospitalization due to very high blood sugar levels (while maintaining such a glucose level in a couple of days, the patient most often falls into a coma), received a refusal from the insurance companies - because "such a diagnosis" is an exclusion from coverage. At the same time, the girl was never diagnosed with diabetes mellitus (which is indeed an exception according to the existing insurance program), high sugar was discovered for the first time, and no other symptoms accompanying diabetes were observed. As a result, the doctor and the patient made a joint decision on hospitalization under the compulsory medical insurance program, since the issue required an urgent solution ...

Subsequently, the patient called her manager at the insurance company to find out if the refusal was justified. The company replied that yes, since "the program provides for outpatient diabetes treatment" ...

It was not possible to get an official comment from Renaissance Insurance at the time of writing.

Insurers will be tougher responsibility for violations in the work of compulsory medical insurance

The Ministry of Health has taken on strengthening the responsibility of insurers working in the compulsory medical insurance system. The insurance companies will set target performance indicators, failure to achieve which will mean a break in relations with the territorial CHI funds and excommunication from the CHI budget funds. This should strengthen the control of insurers over doctors, but it is too early to talk about the transition to the insurance model of medicine, writes Kommersant.

Will compulsory medical insurance be combined with voluntary medical insurance?

Now there is a trend in health insurance to tighten control over everyone. In particular, the Ministry of Health intends to increase the liability of insurers working in the CHI system. Insurers, in turn, want to be able to terminate contracts with medical institutions that are performing poorly.

The Ministry of Health is developing amendments to two laws: on compulsory medical insurance and on the organization of insurance business in the Russian Federation. The amendments should determine the conditions and procedure for the operation of agreements on financial security between the territorial CHI funds and medical insurers. As well as the procedure for medical insurers to conduct an examination of the quality of the Compulsory medical insurance help.

The insurance community is also hatching the idea of ​​combining voluntary medical insurance with compulsory medical insurance. In the near future, it is necessary to determine what and how much it costs in the CHI, in order to concretize what services the state will provide under the CHI, which ones - under the VMI, and which citizens will be able to pay in partnership with the state, combining two insurances.

Patients, and is also ready to take care of patients transferred from other clinics.

How to organize planned hospitalization at the Central Clinical Hospital?

Doctor's consultation before hospitalization.

Before making a planned hospitalization, you need to consult with a specialist doctor at the clinic or the head of the department where you would like to be hospitalized. We have prepared detailed information about the departments and centers of the hospital and polyclinic in the corresponding sections of the CDC website.

To do this, you can:

The hospital employee will not only make an appointment with you, but also write out a pass, as well as give the necessary explanations on the consultation process.

At the appointment, a specialist doctor will assess the need for hospitalization, advise you on all issues related to hospitalization and your diagnosis, draw up a preliminary plan of examination and treatment, and a consultation protocol.

Planned hospitalization for compulsory medical insurance.

In accordance with article 9.2. Federal Law of 12.01.1996 No. 7-FZ "On Non-Commercial Organizations", a budgetary institution carries out its activities in accordance with the subject and objectives of the activity, determined in accordance with federal laws, other regulatory legal acts, municipal legal acts and the charter.

In accordance with the Decree of the President of the Russian Federation of 03.11.2012 No. 1473, the Federal State Budgetary Institution "Central Clinical Hospital with a Polyclinic" is included in the list of federal state unitary enterprises and federal state institutions subordinate to the Administrative Department of the President of the Russian Federation.

In accordance with the Charter of the Federal State Budgetary Institution "Central Clinical Hospital with a Polyclinic", approved by order of the Administrative Department of the President of the Russian Federation No. 392 dated September 27, 2017, the Administrative Department of the President of the Russian Federation is the founder. According to clause 2.1. Of the Charter, the main goal of the Institution's activities is to provide medical care to persons whose medical care is entrusted to the Administrative Department in accordance with the legislation of the Russian Federation (Decree of the President of the Russian Federation of September 17, 2008 N 1370 "On the Administrative Department of the President of the Russian Federation"). The provision of medical care to persons specified in the Regulations on the Administrative Department of the President of the Russian Federation is carried out at the expense of budgetary allocations provided in the federal budget to the Administrative Department for these purposes, as well as at the expense of compulsory medical insurance funds (subparagraph 5 of paragraph 2 of the Decree of the President of the Russian Federation of September 17 2008 N 1370).

Everyone knows about compulsory health insurance, or compulsory health insurance, but when mentioning voluntary health insurance, voluntary health insurance, people have a lot of questions.

So what are the advantages and disadvantages of this type of insurance, is it worth making a choice in favor of the VHI program?

Pros of voluntary health insurance

By purchasing a VHI policy, a citizen can enjoy the following advantages of his choice:

• you can choose an insurance company yourself.
  Having studied the reputation and terms of cooperation, you can make an informed choice in favor of the preferred insurer;
• fully the citizen independently determines the composition of the insurance program Simply put, the policyholder will decide for himself which points of the program he needs and which not. Consequently, he will pay only for what he chose himself, and not for what was imposed on him;
• as well as the composition of the insurance program, the duration of its validity can vary significantly... So, the policyholder can choose the period during which the terms of the contract will be valid: several years, several months, several days or even a day;
• when it comes to highly qualified medical care, VHI is the best way to get it at no extra cost... The purchase of such a policy is just the case when you can significantly improve the quality of medical care without significantly increasing your costs for it.

What does the voluntary health insurance program include?

As you can see, there are many advantages.

And what exactly can a citizen get by purchasing a VHI policy?

1. The basic program that is provided compulsory medical insurance policy, is also included in the VHI program by default.
   The policyholder can use the ambulance services on the same grounds as the owner of the compulsory medical insurance policy.
2. Commercial services have at their disposal mobile resuscitation centers, or resuscitation vehicles, equipped with the latest technology, both for children and adults.
3. Although there are not many commercial ambulances, they always live up to their name and arrive very soon indeed.
4. This is achieved due to the fact that special contracts are concluded between insurance companies and such services. As a result, upon receipt of a signal, a car will be immediately dispatched from the nearest station.
5. A separate issue is hospitalization with voluntary medical insurance. The policyholder will not be placed in the nearest medical facility, but in the one that he has chosen himself, or in the one that has entered into an agreement with the insurance company.

The level of service and the quality of work of staff in such medical institutions is an order of magnitude above than in state and municipal. Hospitalization will be full treatment rather than bullying the patient.

Learn how to properly issue a VHI for children, how to properly issue a policy and what documents are needed, who can purchase a VHI policy.

Perhaps you will find out what VHI is for newborns, what is needed to get a VHI policy? Price insurance policy and which program you can choose.

Are there any disadvantages to the voluntary health insurance program?

Of course, any insurance program has both pros and cons. Therefore, citizens who make a choice in favor of VHI must be aware of the difficulties that may await them in order to prepare in advance.

So, the first and most important difficulty is the absence fixed VHI policy fees. Since the price depends on many factors, it cannot be predicted in any way.

For each citizen, the cost of the policy is set individually and even when different citizens choose the same conditions.

Key factors that affect the price of a voluntary health insurance program:

• the age and state of health of the patient;
• prestige and own price requests of the medical organization with which the contract is concluded;
• range of services offered and various additional conditions chosen by the policyholder himself.

The policyholder may lose the benefit. Yes, yes, this is also possible, and although conscientious citizens have absolutely nothing to fear, to know that for whatever reasons, payments under the agreement are not made, it is imperative that:

• if injury or other harm to health was caused intentionally, no payment is made. Thus, the VHI agreement cannot be used for personal gain;
• citizen who inflicted harm to your health while under the influence of alcohol or drugs, also will not be able to count on payment. The state of the policyholder at the time when the damage was caused to health can be determined during the examination;
• finally, no payment is made if the citizen sick or injured as a result of actions that violate the law. Thus, the VHI program cannot be used to "hedge" dangerous illegal actions.

Another rather problematic aspect of VHI agreements is sublimits. These are restrictions that are imposed by the insurance companies themselves and medical organizations when the contract is concluded. Therefore, the text of the document must be read with the utmost care and attention paid to even the smallest details.

Sublimits can include the following:

• some illnesses are not covered by insurance, and payments for them are not made, since their treatment requires disproportionate material costs.
  Funding can come from state budget... In particular, we are talking about mental, oncological, severe infectious diseases, and so on;
• allowed insurance of severe chronic diseases, although not all programs provide this.
  The policyholder may be ordered to pay extra for additional risks that arise in such cases. We can talk about gastric ulcer, hypertension, bronchitis, cholecystitis, and so on. It is important to remember that if chronic illness it will be revealed when the contract is already in force, then either it will be excluded from the policy, or the amount of the insurance premium will be increased - this is completely legitimate;
• cosmetic services and plastic surgery- this is another area of ​​action of sublimits.
  If the policyholder voluntarily ordered plastic surgery or a cosmetic service, then the VHI policy will not apply to all associated costs, as well as to any consequences. This limitation is quite logical, since we are not talking about a disease, but about a conscious expression of will.

Voluntary insurance has one more drawback, which is not without, however, and compulsory medical insurance. If the policyholder's illness is recognized deadly, the policy will not provide it with payment.

Super high risks cannot be included in the terms of the contract, since financial resources are limited in any case, and companies that provide voluntary health insurance do not undertake to finance such cases.

Otherwise, calculating rates and long-term insurance coverage would be extremely difficult.

Regulatory framework for voluntary health insurance

It should be noted that the Russian legislation regulates CHI in much more detail. However, attention is paid to the VHI.

All key provisions can be found in the following documents:

• The Civil Code of the Russian Federation - the conclusion of contracts is regulated in article 945, citizens are protected from fraud by articles 178, 395, 1102;
• Tax Code of the Russian Federation - the taxation under VHI contracts is regulated;
• RF Law " Organization of insurance business in the Russian Federation»No. 4015-1 dated November 27, 1992 - establishes the rights and obligations of the parties when concluding insurance contracts;
• documents on which amendments were made to key insurance laws: Federal Laws No. 157-FZ of December 31, 1997, No. 182-FZ of July 17, 1999, No. 57-FZ of May 29, 2002.

What does the policyholder receive when concluding a VHI contract?

Having concluded an agreement, you can count on:

• accelerated service and the fastest possible hospitalization;
• accommodation in comfortable conditions, in a ward with a pleasant atmosphere;
• polite and friendly attitude of the staff;
• 100% compliance with the rules for treating patients;
• taking into account personal requirements and wishes in the provision of medical care;
• using only proven, modern drugs and techniques.

The main nuisance that can be avoided when attacking insured event, - large expenses that are partially or fully repaid by the insurance company.

The VHI program for employers also has a separate plus, since it allows you to take care of employees and make them confident that they are important for their company and will not be left without help and support in a difficult situation.

How to conclude a VHI contract?

To conclude a VHI contract, you need:

• to study the offers of insurance companies, among the services of which there is the conclusion of such contracts;
• choose the most preferred insurer, taking into account the reputation and conditions of cooperation;
• contact a company representative, agree on the time of concluding a contract;
• before you sign the contract with your signature, carefully study its terms and ask questions of interest.

Prices depend on many factors, so it is impossible to give specific numbers. The average basic cost for a person without chronic diseases who chooses the basic program starts at 15 thousand rubles per year. Additional services or health problems of the policyholder add value.

What to look for when concluding a contract:

1. Choose your insurer as carefully as possible. Look for information about firms in unbiased sources, such as specialized forums.
2. Find out which medical facilities the insurer works with. Find out the list of services that you can order.
3. Don't sign the contract without looking... Take the time to study it thoroughly and clarify all the incomprehensible points.
4. Do not try to use the VHI program for personal gain - it will be a waste of money.
5. Pay only for what you think necessary... Do not agree to include additional clauses "just in case." Remember: insurance agent it's just important to sell you the contract as expensive as possible.
6. Don't lose your contract... You should be able to refer to its text at any time.
7. If you are an employer, be sure to use all Benefits LCA to take care of their employees.
8. If you are an employee, carefully consider all the proposals of the contract that is offered to you on behalf of the employer.