《保险研究》20260308-《商业健康保险风险分类因素的分级规制路径》（李晨珂、马宁）

［摘   要］我国商业健康保险的风险分类面临着公平性质疑与规范缺失等问题。为消解现实困境，宜以比例原则为基础，对性别、怀孕、基因信息、既往症、家族病史、年龄和用户行为数据等七类在国内外理论与实务中存有争议的代表性因素进行分析，构建商业健康保险风险分类的法律规制架构。具言之，应运用比例原则中的适当性原则明确风险分类因素的范围划定，依据必要性原则确立其分级使用的分层标准，通过均衡性原则实现不同法益间的审慎权衡。由此构建出“禁止使用、限制使用、允许使用”的三阶规制模式。即对性别和怀孕因素实施禁止使用模式；对基因信息、既往症与家族病史适用限制使用模式；对年龄及用户行为数据则采用允许使用模式。

［关键词］商业健康保险；风险分类；分级规制；比例原则

［基金项目］中国保险学会2025年年度研究项目《商业保险参与社会治理的法律机制研究》（ISCKT2025-N-1-28）成果。

［作者简介］李晨珂，西安交通大学法学院博士研究生；马宁，西安交通大学法学院教授。

A Tiered Regulatory Approach to Risk Classification Factors in Commercial Health Insurance

LI Chen-ke，MA Ning

Abstract：The risk classification in China′s commercial health insurance faces challenges such as fairness concerns and a lack of normative standards.To address these practical difficulties，it is advisable to adopt the principle of proportionality as a basis for analyzing seven controversial representative factors debated both domestically and internationally in theory and practice.These factors include gender，pregnancy，genetic information，pre-existing conditions，family medical history，age，and user behavioral data.On this foundation，a legal regulatory framework for risk classification in commercial health insurance should be established.Specifically，the suitability sub-principle under the principle of proportionality should be applied to define the scope of risk classification factors;the necessity sub-principle should be employed to establish hierarchical criteria for their graded application;and the balancing sub-principle should guide the careful weighing of different legal interests.This approach leads to the construction of a three-tier regulatory model of “prohibition，restriction，and permission”.In practice，this means applying a prohibition model to factors such as gender，pregnancy，a restriction model to genetic information，pre-existing conditions，and family medical history，and a permission model to age and user behavioral data.

Key words：commercial health insurance;risk classification;tiered regulation;principle of proportionality