《保险研究》20250505-《我国“带病体”健康险可持续发展问题研究》（于梦迪、李明蔚、陈凯、刘佳程）

［摘   要］为既往症（也称“带病体”）人群提供合适的健康险保障，可以使该人群在面对健康风险时拥有一定的经济防护能力，有助于减少因病致贫、因病返贫现象的发生，并促进社会公平。然而，当前保险市场普遍担忧对既往症人群大力推行健康险会产生逆向选择风险，从而增加保险公司的赔付成本，并影响健康险行业的可持续发展。本文基于我国某款具有代表性的“百万医疗险”产品的数据，实证评估了引入带病投保选项对产品利润及公司可持续经营的影响。研究发现：放宽投保限制或有利于定价效率的提升；相比普通人群，极端人群的理赔风险更加难以估测，标定目标客户群体时应尽可能涵盖范围更广的人群；在积极理赔把控下，允许“带病体”投保并不必然降低经营利润。

［关键词］健康险；既往症人群；“带病体”保险；逆向选择

［基金项目］北京大学经济学院中青年教师科研种子基金资助课题“带病体”商业健康保险可持续发展问题研究。

［作者简介］于梦迪，北京大学经济学院博士研究生，研究方向：商业保险与社会保障；李明蔚，北京大学经济学院博士研究生，研究方向：健康保险、农业保险；陈凯（通讯作者），北京大学经济学院副教授、博士生导师，研究方向：保险精算、养老金保险设计以及定价；刘佳程，北京大学经济学院博士研究生，研究方向：健康保险、行为经济学。

A Study on the Sustainable Development of the Health Insurance for People with Pre-Existing Conditions in China

YU Meng-di，LI Ming-wei，CHEN Kai，LIU Jia-cheng

Abstract：Having an adequate health insurance coverage is essential for protecting people with pre-existing conditions against health-related financial risks.It also plays a crucial role in preventing them from lapse or relapse into poverty due to illness，thus enhancing social equity.However，there is an established concern in the insurance market that providing health insurance for those with pre-existing conditions could give rise to adverse selection risks and increased costs for insurers which threatens the sustainability of the health insurance industry.This paper utilizes dataset of a representative “million yuan medical insurance plan” in China to empirically assess the impacts on the plan’s profitability and sustainable operation of the insurer by offering insurance coverage to people with pre-existing conditions.The research demonstrates that relaxing participation requirements may enhance the efficiency of insurance pricing;in comparison with the general people，the claims risk of the extreme group is even harder to be predicted，therefore we should cover the scope of people as large as possible when deciding on the targeted consumer group;with proactive claims payment controls in place，allowing individuals with pre-existing conditions to be insured in the plan does not necessarily lower the insurance company's potential profitability.

Key words：health insurance;people with pre-existing conditions;health insurance covering pre-existing conditions;adverse selection