New regulations on refusal to pay for medical examination and treatment costs under health insurance

Lawyer Nguyen Thi Thuy, YouMe Law Firm LLC, replied:

Article 51 of Decree No. 188/2025/ND-CP stipulates the refusal to pay for health insurance examination and treatment costs as follows:

1. Resignation to pay for health insurance examination and treatment costs is the social insurance agency's refusal to pay for health insurance examination and treatment costs determined to be inconsistent with the provisions of law on health insurance and health insurance examination and treatment during the assessment process and before payment to medical examination and treatment facilities.

2. The reason for the refusal to pay must be clearly stated in the appraisal record, including the costs of medical examination and treatment for health insurance that the social insurance agency requests to pay in the electronic environment and must be paid automatically when the medical examination and treatment facility sends data. Representatives of social insurance agencies and representatives of medical examination and treatment facilities agreed to sign a record of appraisal of medical examination and treatment costs under health insurance as a basis for settlement within the period prescribed in Point b, Clause 2, Article 32 of the Law on Health Insurance.

3. Medical examination and treatment facilities have the right to recommend the social insurance agency to reconsider the refusal to pay for medical examination and treatment costs under health insurance or recommend the competent authority to consider and resolve them according to the provisions of law.

Thus, the refusal to pay for medical examination and treatment costs under health insurance is regulated as above.