National Health Insurance Act

When the total sum of the amount of co-payment, etc. (or, where high-cost medical expenses set forth in paragraph (1) of the preceding Article are paid, the amount obtained by deducting the amount equivalent to the amount so paid), the amount to be borne by a user of Long-Term Care Service pursuant to the provisions of Article 51, paragraph (1) of the Long-Term Care Insurance Act (or, where expenses for High-Cost Long-Term Care Service set forth in the same paragraph are paid, the amount obtained by deducting the amount so paid) and the amount to be borne by a user of Preventive Long-Term Care Service pursuant to the provisions of Article 61, paragraph (1) of the same Act (or, where expenses for High-Cost Preventive Long-Term Care Service set forth in the same paragraph are paid, the amount obtained by deducting the amount so paid) is extremely large, Municipalities and Societies shall pay expenses for high-cost medical treatment combined with long-term care to the relevant Householder or Society member; provided, however, that this shall not apply if no benefit for medical treatment, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing or special medical expenses were paid and no difference was paid pursuant to the provisions of Article 56, paragraph (2) with respect to the medical treatment relevant to such amount of co-payment, etc.

The provisions of paragraph (2) of the preceding Article shall apply mutatis mutandis to the payment of medical expenses combined with high-cost long-term care.

With respect to an insured person's childbirth or death, Municipalities and Societies shall make a childbirth and childcare lump sum payment or pay funeral expenses or grant benefits for funeral services pursuant to the provisions of Municipal Ordinance or constitution; provided, however, that they may refrain from taking all or part of these measures when any special reason exists.

In addition to the insurance benefits set forth in the preceding paragraph, Municipalities and Societies may pay injury and illness benefits or provide any other insurance benefit pursuant to the provisions of Municipal Ordinance or constitution.

Municipalities and Societies may entrust affairs concerning the payment of the insurance benefits set forth in paragraph (1) and the injury and illness benefits set forth in the preceding paragraph to a Federation of National Health Insurance Associations or the organization.

Where a current or former insured person falls under any of the following items, no benefits for medical treatment or benefit for medical expenses for Dietary Treatment for inpatients, Living Support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses for home-nursing, special medical expenses or transport expenses (hereinafter referred to as "Benefits for Medical Treatment, etc." in this Section) shall be provided for the relevant period:

when such insured person is committed to a juvenile training school or any other institution similar thereto;

when such insured person is confined to a work facility or any other facility similar thereto.

When an insured person suffers illness or injury intentionally, or due to said person committing a criminal act intentionally, no Benefits for Medical Treatment, etc. shall be paid for such illness or injury.

When an insured person suffers illness or injury due to a conflict, state of drunkenness or extreme misconduct, Benefits for Medical Treatment, etc. for such illness or injury may not be paid in whole or in part.

When a current or former insured person fails to follow instructions concerning medical treatment without a justifiable reason for not doing so, Municipalities and Societies may refrain from providing part of the applicable Benefits for Medical Treatment, etc.

When a current or former insured person or a person who is to receive insurance benefits fails to comply with an order issued pursuant to the provisions of Article 66 or refuses to answer questions or to undergo a medical examination without a justifiable reason for not doing so, Municipalities and Societies may refrain from providing all or part of the applicable Benefits for Medical Treatment, etc.

In cases where a Householder or Society member who is eligible for insurance benefits (including the payment of a difference pursuant to the provisions of Article 43, paragraph (3) or Article 56, paragraph (2); hereinafter the same shall apply) has become delinquent in the payment of insurance premiums and where said person still fails to pay said insurance premiums during the period until the period specified by Order of the Ministry of Health, Labour and Welfare has elapsed from the due date for payment of said insurance premiums even though the Municipality or Society concerned has carried out encouragement of insurance premium payment, etc., Municipalities and Societies shall temporarily suspend the payment of insurance benefits in whole or in part, as provided by Order of the Ministry of Health, Labour and Welfare, unless a disaster or any other special circumstances specified by Cabinet Order are deemed to exist under which such insurance premiums failed to be paid.

Even if the period specified by Order of the Ministry of Health, Labour and Welfare as prescribed in the preceding paragraph has not elapsed, in cases where a Householder or Society member who is eligible for insurance benefits is still delinquent in the payment of insurance premiums even though the Municipality or Society concerned has carried out encouragement of insurance premium payment, etc., Municipalities and Societies may temporarily suspend the payment of insurance benefits in whole or in part, as provided by Order of the Ministry of Health, Labour and Welfare, unless a disaster or any other special circumstances specified by Cabinet Order are deemed to exist under which such insurance premiums failed to be paid.

In cases where a Householder or Society member who is subject to the application of Article 54-3, paragraph (1) or the main clause of paragraph (2) and for whom the payment of insurance benefits has been temporarily suspended in whole or in part pursuant to the provisions of the preceding two paragraphs still fails to pay delinquent insurance premiums, Municipalities and Societies may, upon prior notice to such Householder or Society member as provided by Order of the Ministry of Health, Labour and Welfare, deduct the amount of such Householder's or Society member's delinquent insurance premiums from the amount of insurance benefits whose payment has been so suspended temporarily.

When the event giving rise to benefits is caused by an act of a third party and Municipalities and Societies provide insurance benefits, they shall obtain, to the extent of the amount of said benefits (or, when such insurance benefits are benefits for medical treatment, the amount calculated by deducting, from the amount of expenses incurred in such benefits for medical treatment, the amount equivalent to the co-payment to be borne by the insured person with respect to such benefits for medical treatment; hereinafter the same shall apply in paragraph (1) of the following Article), the right to claim compensation for damages held by the insured person against the third party.

In the case referred to in the preceding paragraph, when a person to be granted insurance benefits receives compensation for damages for the same reason from a third party, Municipalities and Societies shall be exempted from the responsibility to pay said insurance benefits to the extent of the amount of such compensation.

In order to ensure the appropriate implementation of insurance benefits by the Municipalities within the prefecture, in the cases specified by Order of the Ministry of Health, Labour and Welfare as cases found necessary from a wide-area or specialized perspective, a prefecture may, upon entrustment from a Municipality, carry out all or part of the affairs of collecting or receiving damages pertaining to the right of claim under paragraph (1) that the Municipality has acquired pursuant to the provisions of that paragraph.

Municipalities and Societies, and prefectures that carry out affairs under the provisions of the preceding paragraph upon entrustment from Municipalities, may entrust the affairs of collecting or receiving damages pertaining to the right of claim under paragraph (1) acquired pursuant to the provisions of that paragraph to a Federation of National Health Insurance Associations set forth in Article 45, paragraph (5) that is specified by Order of the Ministry of Health, Labour and Welfare.

The national government is to endeavor to take the measures necessary for the smooth implementation of those affairs for a prefecture that carries out the affairs under the provisions of paragraph (3) upon entrustment from a Municipality.

When there is a person who has received insurance benefits by means of deception or other wrongful conduct, Municipalities and Societies may collect all or part of the amount of such benefits from that person.

In the case referred to in the preceding paragraph, when the insurance benefit is granted because a health insurance-covered physician who is engaged in medical care at a health insurance-covered medical institution or an attending physician as set forth in Article 88, paragraph (1) of the Health Insurance Act has made a false entry on the medical certificate which is to be submitted to a Municipality or Society, the Municipality or Society may order said health insurance-covered physician or attending physician to pay the money to be collected pursuant to the preceding paragraph jointly and severally with the person who received said insurance benefit.

A prefecture may, upon entrustment from a Municipality, carry out, of the affairs of collecting or receiving the amounts that the Municipality causes a health insurance-covered medical institution, etc. or designated home-nursing provider to refund and to pay pursuant to the provisions of the preceding paragraph, those that require a wide-area response or are highly specialized.

When Municipalities and Societies find it necessary in relation to insurance benefits, they may order the relevant current or former insured person or the relevant person who is to receive insurance benefits to submit or present a document or any other article, or may have their personnel question or diagnose any of the above persons.

The right to receive insurance benefits may not be transferred, pledged as collateral, or levied.

Taxes and other public dues may not be imposed on the basis of money and goods received as payment of insurance benefits.