Health Insurance Act

With regard to sickness and injury of a specially-insured day laborer, benefits for medical treatment listed in each item of Article 63, paragraph (1) are paid.

To receive benefits for medical treatment, a specially-insured day laborer must fall under any of the following items on the day on which the benefits are received; provided, however, that in the case of item (ii), benefits for medical treatment are not provided for sickness or injury for which a benefit for medical treatment was provided under item (i) or any sickness or injury caused thereby:

insurance premiums have been paid for the specially-insured day laborer for 26 days or more in total in the two months preceding the month including the day on which the benefits are received or for 78 days or more in total in the six months preceding the month including that day; or

one year (five years with regard to the sicknesses designated by the Minister of Health, Labour and Welfare) has not passed since the date of commencement of the benefit for medical treatment received for the relevant sickness or injury (including those that caused the sickness or injury; the same applies hereinafter in this paragraph) pursuant to the preceding item (if special medical expenses (including medical expenses paid pursuant to the provisions of Article 132 applied mutatis mutandis to Article 145, paragraph (6); the same applies hereinafter in this item), expenses for in-home long-term care services pursuant to the provisions of the Long-Term Care Insurance Act (limited to expenses for services equivalent to designated in-home services; the same applies hereinafter in this item, Article 135, paragraph (4), and Article 145, paragraph (1)), expenses for special in-home long-term care services (limited to expenses for services equivalent to in-home services or services equivalent thereto; the same applies hereinafter in Article 135, paragraph (4), and Article 145, paragraph (1)), expenses for community-based long-term care services (limited to expenses for services equivalent to designated community-based services; the same applies hereinafter in this Article, Article 135, paragraph (4), and Article 145, paragraph (1)), expenses for special community-based long-term care services (limited to the payment pertaining to services equivalent to community-based services or pertaining to services equivalent thereto; the same applies hereinafter in this item, Article 135, paragraph (4), and Article 145, paragraph (1)), expenses for long-term care facility services (limited to expenses for services equivalent to designated facility services; the same applies hereinafter in this item, Article 135, paragraph (4), and Article 145, paragraph (1)), expenses for special long-term care facility services (limited to expenses for services equivalent to facility services; the same applies hereinafter in this item, Article 135, paragraph (4), and Article 145, paragraph (1)), expenses for services to prevent long-term care (limited to expenses for services equivalent to designated services to prevent long-term care; the same applies hereinafter in this item, Article 135, paragraph (4), and Article 145, paragraph (1)), or expenses for special services to prevent long-term care (limited to expenses for services equivalent to services to prevent long-term care or services equivalent thereto; the same applies in this paragraph, Article 135, paragraph (4), and Article 145, paragraph (1)) were paid for the relevant sickness or injury before that date of commencement, the date of commencement of payment of special medical expenses, or payment of expenses for in-home long-term care services, expenses for special in-home long-term care services, expenses for community-based long-term care services, expenses for special community-based long-term care services, expenses for long-term care facility services, expenses for special long-term care facility services, expenses for services to prevent long-term care, or expenses for special services to prevent long-term care, pursuant to the provisions of the Long-Term Care Insurance Act) (excluding cases that fall under the preceding item);

When a specially-insured day laborer proves that the laborer falls under item (i) of the preceding Article with a specially-insured day laborer's insurance book and applies, the insurer must issue a qualified recipient card which shows confirmation of the proof or add the confirmation to a qualified recipient card which has already been issued.

When intending to receive benefits for medical treatment listed in each item of Article 63, paragraph (1), a specially-insured day laborer is to select a hospital, clinic, or pharmacy from those listed in paragraph (3), item (i) or (ii) of the same Article, submit the laborer's qualified recipient card thereto, and receive the benefits therefrom.

The qualified recipient card referred to in the preceding paragraph must have been confirmed pursuant to the provisions of paragraph (3) and thereby prove that the recipient requirements for sickness and injury prescribed in paragraph (2) are met.

The form of a qualified recipient card, the confirmation pursuant to the provisions of paragraph (3), and other necessary matters concerning a qualified recipient card are specified by Order of the Ministry of Health, Labour and Welfare.

When a specially-insured day laborer (excluding a person who receives medical treatment consisting of hospitalization in a sanatorium ward and care and other nursing incidental to that medical treatment after the month which contains the person's 65th birthday (hereinafter referred to as a "specially-insured day laborer receiving specified long-term hospitalization")) submits the laborer's qualified recipient card to a hospital or clinic which the laborer selected from those listed in Article 63, paragraph (3), item (i) or (ii) and receives dietary treatment along with benefits for medical treatment listed in paragraph (1), item (v) of the same Article from the hospital or clinic, dietary treatment expenses for inpatients pertaining to the dietary treatment are paid.

The provisions of Article 129, paragraphs (2), (4) and (5) apply mutatis mutandis to the payment of dietary treatment expenses for inpatients.

When a specially-insured day laborer receiving specified long-term and hospitalization submits the laborer's qualified recipient card to a hospital or clinic which the laborer selected from those listed in Article 63, paragraph (3), item (i) or (ii) and receives living support along with benefits for medical treatment listed in paragraph (1), item (v) of the same Article from the hospital or clinic, living support expenses for inpatients pertaining to the living support are paid.

The provisions of Article 129, paragraphs (2), (4) and (5) apply mutatis mutandis to the payment of living support expenses for inpatients.

When a specially-insured day laborer submits the laborer's qualified recipient card and receives evaluation treatment, patient-requested treatment, selective treatment, or partially uninsured treatment from a hospital, clinic, or pharmacy that the laborer selected from those listed in Article 63, paragraph (3), item (i) or (ii), medical expenses combined with treatment outside insurance coverage are paid for expenses required for that treatment.

The provisions of Article 129, paragraphs (2), (4) and (5) apply mutatis mutandis to the payment of medical expenses combined with treatment outside insurance coverage.

When an insurer finds it difficult to pay benefits for medical treatment or expenses for dietary treatment for inpatients, living support expenses for inpatients, or medical expenses combined with treatment outside insurance coverage (hereinafter referred to as a "benefits for medical treatment, etc." in this paragraph) or finds it unavoidable in cases where a specially-insured day laborer has received any medical care, medication or treatment from a hospital, clinic, pharmacy or other person not listed in Article 63, paragraph (3), items (i) and (ii), it may pay medical expenses in lieu of benefits for medical treatment, etc.

The provisions of the preceding paragraph apply when a specially-insured day laborer receives medical care or medication from a hospital, clinic or pharmacy listed in Article 63, paragraph (3), item (i) or (ii) without the confirmation prescribed in Article 129, paragraph (3) and the insurer finds that the lack of confirmation was due to urgent and unavoidable reasons.

When a specially-insured day laborer submits the laborer's qualified recipient card to a designated home-nursing provider selected by the laborer, and receives designated home-nursing from the provider, with regard to expenses incurred in the designated home-nursing, medical expenses for home-nursing are paid.

The provisions of Article 129, paragraphs (2) and (5) apply mutatis mutandis to the payment of medical expenses for home-nursing.

When a specially-insured day laborer has been transported to a hospital or clinic in order to receive medical treatment (including medical treatment covered by medical expenses combined with treatment outside insurance coverage or by special medical expenses), an amount calculated pursuant to Order of the Ministry of Health, Labour and Welfare referred to in Article 97, paragraph (1) as transport expenses.