China Insurance Association Issues Draft Model Clauses for Three Medical Insurance Categories

On September 16, 2026, the Insurance Association of China released draft model clauses for long-term medical insurance, short-term medical insurance, and city-customized commercial medical insurance (Huiminbao), bringing the three major commercial medical insurance categories into a unified contract template framework for the first time. Industry data show that in 2024, China's commercial medical insurance scale surpassed critical illness insurance for the first time, becoming the largest category in the health insurance market. Previously, medical insurance products on the market had clauses of varying length and wording, and different products were inconsistent on issues such as when the waiting period begins, what constitutes reasonable and necessary treatment, and the scope of exclusions.

In September 2025, the National Financial Regulatory Administration issued the Guiding Opinions on Promoting the High-Quality Development of Health Insurance, proposing the formulation of model health insurance clauses, clarifying coverage scope and exclusions, and advancing the standardization, plain-language drafting, and simplification of clauses. The current draft standardizes the definitions of 24 commonly used concepts, including "first-time insurance purchase," "reasonable and necessary," "initial confirmed diagnosis," and "specialist physician," and regulates how key elements such as the waiting period, deductible, benefit limit, agreed types of medical institutions, and benefit schedule are set, with some specific elements to be filled in by insurers at their discretion.

On consumer protection, the draft regulates exclusion clauses, using prominent markings to highlight key points, and specifies eight exclusion clauses including war and drunk driving, while insurers may fill in other content as needed; it also encourages reducing exclusion items. The draft further regulates service standards such as claims application materials and claims processing time limits, clarifies the logic for deducting the deductible, and encourages allowing treatment outside the agreed medical institution scope in sudden critical, acute, or severe illness situations. The benefit schedule is explicitly defined as an important component of the clauses, presenting core coverage information visually through a standardized table.

For short-term medical insurance, the draft explicitly requires that renewal is not guaranteed; for long-term medical insurance with adjustable rates, it specifies the trigger conditions, timing, upper limits, procedures, and information disclosure requirements for rate adjustments. On specific drug cost coverage, the draft specifies that the list of specific drugs agreed by insurers must cover the commercial health insurance drug coverage list published by the Insurance Association of China.

All three model clauses are divided into basic items, optional items, and sections to be filled in by insurers. Basic items must be quoted in full by insurers and include certain basic concept statements and definitions; optional items, if selected for use, must also be quoted in full; other content is to be filled in by insurers based on practice. The Insurance Association of China said that beyond basic and optional items, the model clauses allow insurers to add content based on practice, balancing generality and flexibility.