Municipalities and Societies, when they find 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 "Benefits for Medical Treatment, etc." in this paragraph and the following paragraph), or when, in cases where an insured person has received any medical care, medication or treatment at or from a hospital, clinic, pharmacy or any other person other than a health insurance-covered medical institution, etc., a Municipality or Society finds it unavoidable, may pay medical expenses in lieu of Benefits for Medical Treatment, etc.; provided, however, that this shall not apply during any period in which the Householder or Society member of the household to which said insured person belongs is subject to the application of Article 54-3, paragraph (1) or the main clause of paragraph (2) with respect to said insured person.
市町村及び組合は、療養の給付若しくは入院時食事療養費、入院時生活療養費若しくは保険外併用療養費の支給（以下この項及び次項において「療養の給付等」という。）を行うことが困難であると認めるとき、又は被保険者が保険医療機関等以外の病院、診療所若しくは薬局その他の者について診療、薬剤の支給若しくは手当を受けた場合において、市町村又は組合がやむを得ないものと認めるときは、療養の給付等に代えて、療養費を支給することができる。ただし、当該被保険者の属する世帯の世帯主又は組合員が当該被保険者について第五十四条の三第一項又は第二項本文の規定の適用を受けている間は、この限りでない。
Where an insured person has received any medical care or medication at or from a health insurance-covered medical institution, etc. without receiving confirmation of being an insured person by electronic eligibility confirmation, etc., and when Municipalities and Societies find that the failure to receive such confirmation was due to an emergency or any other unavoidable reason, they shall pay medical expenses in lieu of Benefits for Medical Treatment, etc.; provided, however, that this shall not apply during any period in which the Householder or Society member of the household to which said insured person belongs is subject to the application of Article 54-3, paragraph (1) or the main clause of paragraph (2) with respect to said insured person.
The amount of medical expenses shall be determined by the Municipality or Society based on the amount calculated by deducting, from the amount calculated for such medical treatment (excluding Dietary Treatment and Living Support), the amount calculated by multiplying such amount by the applicable ratio listed in the items of paragraph (1) of Article 42, in accordance with the categories listed in the items of the same paragraph, and the amount calculated by deducting, from the amount of expenses calculated for such Dietary Treatment or Living Support, the amount of Standard Co-payment for Dietary Treatment or Standard Living Expense Co-payment, respectively.
In calculating the amount of expenses set forth in the preceding paragraph, the provisions of Article 45, paragraph (2) shall apply mutatis mutandis to cases where benefit for medical treatment shall be received, those of Article 52, paragraph (2) shall apply mutatis mutandis to cases where expenses for Dietary Treatment for inpatients shall be received, those of Article 52-2, paragraph (2) shall apply mutatis mutandis to cases where expenses for Living Support for inpatients shall be received, and those of paragraph (2) of the preceding Article shall apply mutatis mutandis to cases where medical expenses combined with treatment outside insurance coverage shall be received; provided, however, that such amount shall not exceed the amount of expenses actually incurred in the relevant medical treatment.
前項の費用の額の算定については、療養の給付を受けるべき場合においては第四十五条第二項の規定を、入院時食事療養費の支給を受けるべき場合においては第五十二条第二項の規定を、入院時生活療養費の支給を受けるべき場合においては第五十二条の二第二項の規定を、保険外併用療養費の支給を受けるべき場合においては前条第二項の規定を準用する。ただし、その額は、現に療養に要した費用の額を超えることができない。
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