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腰痛治療の保険の適用には注意が必要

医者

腰痛に悩んで整形外科を何度受診してもなかなか痛みを解消することができないという場合には、鍼やマッサージなどの生態や整骨院などに通う人も多くいるというのも一つの現実ですが、このような場合に健康保険は適用できるのでしょうか?

知っておかないと損をする場合もあるこの健康保険の適用について紹介していきましょう。

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健康保険の適用についての知識を身に着けよう

医師

腰痛の主な専門は整形外科とされていますが、それ以外の整骨院・接骨院・鍼灸・マッサージについて健康保険が適用できるのかどうか、適用される場合はどうか、どのような形で適用されるのかについて詳しく説明していくことにしましょう。

どの程度保険が適用されるのか?

基本的に整骨院・接骨院・鍼灸・マッサージは厚生労働省の基準によって健康保険の適用ができる範囲が決められています。保険医療機関として診療を行うには厚生労働省への届け出が必要で、この届けを受理された医療機関ではある程度まで健康保険の適用が認められています。

整骨院・接骨院・鍼灸・マッサージのなかには保険が使えるという事を広告しているところがありますが、わざわざそういった情報を掲示しているのはそのためです。

ですので、すべての治療に健康保険が使えるわけではないという事、また健康保険適用の認可を受けていない診療機関では健康保険が使えないという事をまず知っておくべきでしょう。では、次にもし健康保険が適用できる診療機関の場合、どのような場合に健康保険が使えるのかどうかを見ていくことにしましょう。

どのような場合に保険が適用されるのか?

まず、整骨院や接骨院ではどのような場合に健康保険が適用されるのでしょうか?整体師や接骨の国家資格として柔道整復師というものがありますが、これらの資格を持っている診療機関では次の5つの病状についてのみ健康保険の適用が認められています。

その病状は骨折・不全骨折・打撲・脱臼・捻挫の5つになります。ただし、病院や診療所などで診療を受けている場合に別の診療機関で治療を受けても健康保険は適用されません。診療を受けている病院の医師から、他の診療機関で治療を受けるという同意書をもらうことができれば保険を適用することができます。それ以外の場合は全額自己負担になるという事を覚えておきましょう。

また健康保険が適用された場合、病院や診療所と同じように診察後の支払い時に健康保険が適用されるのも整骨院・接骨院だけに認められている制度です。

では、次に鍼灸・整体・マッサージの場合はどうでしょうか?
鍼灸の場合もそれぞれの国家資格を持っている診療機関であることがまず条件になります。この場合に健康保険が適用される病状は、リウマチ・神経痛・ムチ打ち・腰痛・五十肩・頚腕症の6つの場合のみに限ります。

体がだるくてつらい・筋肉痛がひどい・肩こりが気になるといった症状で鍼灸の治療を受けても健康保険を適用することはできません。整体やマッサージの場合は、あん摩・マッサージの国家資格を持っている診療機関になります。

ここでも病状が限定されており、関節拘縮と筋麻痺の2つだけです。これらは様々な病気の後遺症としてその治療のために整体やマッサージに通院した場合に健康保険が適用できるという決まりになっているためです。

ただし、後遺症に関する治療という事で、他の診療機関と異なる点として唯一病院や診療所と同時に診察を受けても健康保険を適用することができます。ただその場合にも、利用できる期間は3か月間で、それ以降は病院の医師の同意書が必要になります。

健康保険が適用される場合にはどのように支給されるのか?

整骨院・接骨院に関しては先述の通り診察後の支払い時に健康保険が適用されることを説明しましたが、これは受任医療制度というものが整骨院・接骨院には認められているからです。この受任医療を適用するには患者側が委任状にサインする必要があります。

他の診療機関の場合には一度全額を支払ってから健康保険に申請して支給してもらうという方法になります。この際、療養費支給申請書と合わせ、病院の医師の同意書と診療機関の領収書が必要になります。

稀に健康保険の対象として疑われると健康保険が判断した場合には、保険適用額の支給に当たって問い合わせてきたり、詳しい説明を求められたりするケースがあります。病院や診療所で施している処置以外の診療機関で保険の適用がここまで厳しい理由には、次のことが挙げられます。

まず、これらの診療機関での治療には医学的根拠が乏しいと考えられているという点が一つ、もう一つはあたかも保険適用できる症状と偽って健康保険の適用を申請するといったケースが急増したため判断基準を厳格化したという点がもう一つです。場合によっては健康保険から適用できませんという回答が来る場合もあると聞きます。自分の腰痛の治療で病院以外の診療機関を受診した時に健康保険が本当に適用できるかどうかをきちんと確認しておくことで、このようなトラブルを回避することが可能でしょう。

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まとめ:腰痛の受診の前に保険の適用ができるかどうかを確認しよう

上記にわたって説明してきましたが、これらのポイントをまとめておきます。受診の際には健康保険が適用できるかどうかを確認して、損せず腰痛治療を受けられるようにしておきましょう。

  • 整骨院・接骨院は受任医療が受けられる
  • 鍼灸・整体・マッサージは全額支払い後に自己申請が必要
  • 健康保険適用の病状はそれぞれ機関によって異なる
  • 病院の医師の同意書を必ずもらうようにしておく
  • 病院の診察と併用すると保険が適用できない

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