Introduction: Accurate Coverage and Controllable Risk Are Equally Essential
In a medical landscape of increasing surgical volumes and continuously evolving procedures, rigid, templated medical insurance products can no longer meet the diverse needs of hospitals and patients. Surgery is inherently complex, high-risk, and high-responsibility—it involves not only technical uncertainties but also perioperative management challenges. Surgical accident insurance is specifically tailored for this high-risk scenario. But only when it is accurately priced, scientifically structured, and claims-controllable can it become a sustainable insurance solution.
I. Why Surgery Is an Ideal Scenario for Insurance Design
1. Highly Concentrated Risk
Surgical procedures are time-bound, team-based, and technically delineated, making them ideal for defining risk nodes and accountability.
2. Clear and Determinable Claims
Insurance is purchased preoperatively, and predefined complications occurring during or after surgery allow for standard claim judgment with reduced disputes.
3. Strong Risk Awareness Among Patients
Patients undergoing surgery are often more open to purchasing coverage, making it easier to integrate into clinical workflows.
4. Institutional Need for Risk Management
Hospitals can offload compensation burdens, improve communication, and ease post-operative disputes by offering surgical accident insurance.
II. Product Design Logic: From Procedure-Based Classification to Scenario Modeling
Based on tens of thousands of real surgical claims and clinical case data, Yihuibao has built a three-dimensional design system:
1. Surgical Risk Classification
All procedures are graded into three tiers by historical claim ratios and medical norms:
- Category A (High Risk): Cardiac, neurosurgery, thoracic surgery—strongly recommended for mandatory coverage.
- Category B (Medium Risk): GI, hepatobiliary, orthopedics—encouraged for proactive recommendation.
- Category C (Low Risk): Superficial surgeries, minor operations—offered optionally or bundled in packages.
2. Complication Mapping Model
Based on surgery type, associated complications are mapped by likelihood and relevance:
- Neurosurgery: cerebral edema, epilepsy, intracranial hemorrhage.
- Orthopedics: DVT, pulmonary embolism, surgical site infection.
3. Insurance Recommendation System
Preoperative education videos, in-system prompts for doctors, and QR-based self-enrollment for patients help ensure timely and relevant insurance recommendations.
III. Claims Control Mechanism: Embedding Risk Management into the Product Lifecycle
Yihuibao practices a “tri-node” control strategy—at enrollment, claims review, and payout phases:
Enrollment Phase:
- Define covered surgeries; eliminate ambiguous scope.
- Impose preoperative limits to avoid retroactive or opportunistic claims.
- Strictly regulate physician-side recommendation to avoid role confusion with agents.
Claims Review Phase:
- Apply triple validation: case records, clinical progress, and imaging.
- AI-aided tools support initial screening for complication inclusion/exclusion.
Payout Phase:
- Use fixed or capped claim amounts to reduce disputes and subjective interpretation.
- Regularly feed back claims analytics to refine the product model.
Yihuibao has kept surgical accident insurance claims ratios stable at 25%–40% across multiple hospitals—ensuring both customer satisfaction and operational viability.
IV. Service Integration: Making Insurance Truly Usable, Payable, and Controllable
- Preoperative Access: Education posters, doctor-signed suggestions, QR-code registration embedded in the ward.
- Intraoperative Monitoring: Real-time alerts on adverse events via incident reporting systems.
- Postoperative Claims: Dedicated support for document preparation by insurance staff reduces hospital workload.
- Data Feedback: Claims data are analyzed to optimize coverage terms and hospital risk metrics.
Conclusion: Insurance Is a Responsibility Framework, Not Just a Price Tag
Surgical accident insurance is not a price-sensitive commodity—it’s a trust-based solution. Only through a structure grounded in clinical data, driven by real-world scenarios, and governed by risk intelligence, can we truly balance the interests of hospitals, physicians, patients, and insurers. Yihuibao will continue to refine its product logic, building surgical accident insurance that is usable for patients, recommendable by hospitals, and sustainable for insurers.