研究背景：疾病診斷證明書是攸關病人及被保險人權益的重要文件，在診斷證明書開立、書寫過程，及檢附保險給付申請判定間，一旦發生爭議困難，直接或間接困擾的往往不僅僅是開立、書寫診斷證明書的醫師一方而已，此難題的認知差異，涉及了被保險人的期待、醫師的專業原則與保險業的判定標準，倘若三方皆各守立場，將演變出一場又一場「三輸」的噩夢！

研究目的：試圖搭起醫師與保險公司雙方認知的溝通了解，共同以病人權益為目標，減少診斷證明書開立及保險給付申請過程的各方困擾。

研究方法：本研究收集國內各家保險公司自2011年10月01日至10月31日期間，因診斷證明書資料內容的相關疑義，而發函詢問醫師或醫療院所，以解決保險給付判定困難的所有疾病診斷證明書。對於符合上述條件的所有診斷證明書一一進行文本分析，除了以可明示與具明示困難度為兩大主要的分類軸，並進一步詳細歸類爭議問題的種類與數量；此外，依據文本分析結果，對發函詢問的保險理賠部門，進行質性訪談研究，以了解釐清各類情況下，保險公司發函詢問醫師或醫療院所的相關考量或理由。

研究結果：於2011年10月1日至10月31日期間，國內保險公司因診斷書疑義導致保險給付判定爭議，而發函詢問醫師或醫療院所之疾病診斷證明書共有412件，佔所有保險公司當月份共7,742件交查照會數的百分之5.32，更僅佔所有保險公司當月份共23萬127件保險給付申請總數的百分之0.18。此外，分析歸類自412件具保險給付爭議診斷書的所有432個爭議問題中，屬於可明示的診斷書爭議問題佔了76.16% (329/432)，而屬於具明示困難度的有23.84% (103/432)。本研究結果具體顯示的兩個重要發現，其一為保險公司針對疾病診斷證明書疑義而發函詢問的交查照會率其實並不高；其二，屬於可改進或可解決的可明示性診斷書爭議問題比例高達四分之三以上。

研究結論：關於保險給付的申請判定，國內保險公司針對疾病診斷證明書疑義而發函詢問的交查照會率不及百分之0.2；且就開立診斷證明書的醫師而言，面對診斷書相關的保險給付爭議問題，具有可為空間與可期成效的可明示類所佔比率相當的高，而另一方面，需要保險公司多加理解，同時調整認知差距的具明示困難度爭議類別比例，則相對屬於小部分；換句話說，醫師與保險兩大專業，只要有心共同面對與解決診斷書相關之保險給付爭議問題，彼此捐棄成見，建立並維持理性的溝通管道，那麼，雙方於實務面的認知差異定能逐步的拉近，而當前「三輸」局面的解套亦是相當樂觀可期的！

Background︰In Taiwan, all licensed doctors are under obligation of issuing sickness certificates. The sickness certificate is a major instrument for establishing contact and conveying information between two authorities that also have a substantial impact on the life and work situation of the patients. There are variations in how physicians, insurance officers or patients conceive of the problems on sickness certificates with insurance benefit disputes.

Aim︰A study was undertaken to reduce the puzzle among physicians, insurance officers and patients during the process of decision making about sickness benefit by the insurance companies.

Methods︰Information on all 412 sickness certificates during one month in 2011 was analysed to categorize the disputes emerged from the sickness certificates. Two insurance officers working with administration of sickness benefits were interviewed for the reasons considered by the insurance companies.

Results︰The rate of investigation of additional information by the insurance companies for insurance benefit disputes emerged from the contents of sickness certificates is not so high as we think. Qualitative analyses of all 412 sickness certificates include 432 insurance benefit disputes revealed 76% required additional information that could be specified.

Conclusions︰Communication between the two authorities is needed and important. Although the problems about sickness certificates with insurance benefit disputes are complicated and hard, they are not unable to be resolved.

中文部分
王志嘉、呂俊儒、林萍章等(2009)，病歷相關法律議題，財團法人醫院評鑑暨醫療品質策進會出版。
李光真(2011)，賠？不賠？揭開醫療險大黑箱，商業週刊第1240期。
黃文賢(2008)，壽險公司健康保險理賠因素之研究，淡江大學企業管理學系碩士論文。
陳繼堯(1997)，保險經營的思考，核保學報(5)，P141-171。
張紹晋(2011)，商業醫療保險公司形象、醫療保險知識與醫療保險費對顧客投保意願之關係研究，國立臺中技術學院企業管理系事業經營碩士論文。
壽保險業概況，中華民國人壽保險商業同業公會出版，2010。
蘇文斌、林宏誠、陳明國 編著(2007)，保險學學理與實務。

英文部分
1.Arrelöv B., L. Borgquist, et al. (2001). "Do GPs sick-list patients to a lesser extent than other physician categories? A population-based study." Family practice 18(4): 393.
2.Arrelov B., K. Alexanderson, et al. (2007). "Dealing with sickness certification - a survey of problems and strategies among general practitioners and orthopaedic surgeons." BMC Public Health 7: 273.
3.Arrelov B. E., L. Borgquist, et al. (2005). "Influence of local structural factors on physicians' sick-listing practice: a population-based study." Eur J Public Health 15(5): 470-474.
4.Bremander A. B., J. Hubertsson, et al. (2011). "Education and Benchmarking Among Physicians May Facilitate Sick-Listing Practice." Journal of Occupational Rehabilitation.
5.Bremberg S. and T. Nilstun (2000). "Patients' autonomy and medical benefit: ethical reasoning among GPs." Fam Pract 17(2): 124.
6.Campbell A. and J. Ogden (2006). "Why do doctors issue sick notes? An experimental questionnaire study in primary care." Fam Pract 23(1): 125-130.
7.Cohen D. A., M. Aylward, et al. (2009). "Inside the fitness for work consultation: a qualitative study." Occup Med (Lond) 59(5): 347-352.
8.Edlund C. and L. Dahlgren (2002). "The physician's role in the vocational rehabilitation process." Disability & Rehabilitation 24(14): 727-733.
9.Engblom M., K. Alexanderson, et al. (2010). "When physicians get stuck in sick-listing consultations: A qualitative study of categories of sick-listing dilemmas." Work: A Journal of Prevention, Assessment and Rehabilitation 35(2): 137-142.
10.Engblom M., K. Alexanderson, et al. (2011). "Physicians' messages in problematic sickness certification: a narrative analysis of case reports." BMC Family Practice 12(1): 18.
11.Engblom M., K. Alexanderson, et al. (2009). "Characteristics of sick-listing cases that physicians consider problematic--analyses of written case reports." Scand J Prim Health Care 27(4): 250-255.
12.Englund L., G. Tibblin, et al. (2000). "Variations in sick-listing practice among male and female physicians of different specialities based on case vignettes." Scandinavian Journal of Primary Health Care 18(1): 48-52.
13.Fleten N., R. Johnsen, et al. (2004). "Length of sick leave - why not ask the sick-listed? Sick-listed individuals predict their length of sick leave more accurately than professionals." BMC Public Health 4: 46.
14.Gerner U. and K. Alexanderson (2009). "Issuing sickness certificates: a difficult task for physicians: a qualitative analysis of written statements in a Swedish survey." Scand J Public Health 37(1): 57-63.
15.Gulbrandsen P., D. Hofoss, et al. (2007). "General practitioners' relationship to sickness certification." Scand J Prim Health Care 25(1): 20-26.
16.Halvorsen P. A., K. Wennevold, et al. (2011). "Decisions on sick leave certifications for acute airways infections based on vignettes: a cross-sectional survey of GPs in Norway and Poland." Scand J Prim Health Care 29(2): 110-116.
17.Hussey S., P. Hoddinott, et al. (2004). "Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland." BMJ 328(7431): 88.
18..Krohne K. and S. Brage (2007). "New rules meet established sickness certification practice: a focus-group study on the introduction of functional assessments in Norwegian primary care." Scand J Prim Health Care 25(3): 172-177.
19.Löfgren A., J. Hagberg, et al. (2007). "Frequency and nature of problems associated with sickness certification tasks: A cross-sectional questionnaire study of 5455 physicians." Scandinavian journal of primary health care 25(3): 178-185.
20.Löfvander M. and A. Engström (2003). "An observer–participant study in primary care of assessments of inability to work in immigrant patients with ongoing sick leave." Scandinavian Journal of Primary Health Care 21(4): 199-204.
21.Larsson C., A. Sydsjö, et al. (2006). "Obstetricians’ attitudes and opinions on sickness absence and benefits during pregnancy." Acta Obstetricia et Gynecologica Scandinavica 85(2): 165-170.
22.Lindholm C., B. Arrelov, et al. (2010). "Sickness-certification practice in different clinical settings; a survey of all physicians in a country." BMC Public Health 10: 752.
23.Lofgren A., J. Hagberg, et al. (2010). "What physicians want to learn about sickness certification: analyses of questionnaire data from 4019 physicians." BMC Public Health 10: 61.
24.Lofgren A., C. Silen, et al. (2011). "How physicians have learned to handle sickness-certification cases." Scandinavian Journal of Public Health 39(3): 245-254.
25.Miller G., H. Britt, et al. (2004). "Relationship Between General Practitioner Certification and Characteristics of Care." Medical Care 42(8): 770-778.
26.Money A., L. Hussey, et al. (2010). "Work-related sickness absence negotiations: GPs' qualitative perspectives." Br J Gen Pract 60(579): 721-728.
27.Mussener U., K. Festin, et al. (2008). "Positive experiences of encounters with healthcare and social insurance professionals among people on long-term sick leave." J Rehabil Med 40(10): 805-811.
28.Nilsen S., E. L. Werner, et al. (2011). "Considerations made by the general practitioner when dealing with sick-listing of patients suffering from subjective and composite health complaints." Scand J Prim Health Care 29(1): 7-12.
29.Norrmén G., K. Svārdsudd, et al. (2010). "The association of patient's family, leisure time, and work situation with sickness certification in primary care in Sweden." Scandinavian Journal of Primary Health Care 28(2): 76-81.
30.Norrmen G., K. Svardsudd, et al. (2006). "Impact of physician-related factors on sickness certification in primary health care." Scand J Prim Health Care 24(2): 104-109.
31.Norrmen G., K. Svardsudd, et al. (2008). "How primary health care physicians make sick listing decisions: the impact of medical factors and functioning." BMC Fam Pract 9: 3.
32.O'Brien K., N. Cadbury, et al. (2008). "Sickness certification in the general practice consultation: the patients' perspective, a qualitative study." Fam Pract 25(1): 20-26.
33.Reiso H., J. F. Nygård, et al. (2000). "Work ability assessed by patients and their GPs in new episodes of sickness certification." Family practice 17(2): 139.
34.Reiso H., J. F. Nygård, et al. (2001). "Work ability and duration of certified sickness absence." Scandinavian journal of public health 29(3): 218.
35.Rob H., K. Boudien, et al. "Sick-listed employees with severe medically unexplained physical symptoms: burden or routine for the occupational health physician? A cross sectional study." BMC Health Services Research 10.
36.Roope R., G. Parker, et al. (2009). "General practitioners' use of sickness certificates." Occup Med (Lond) 59(8): 580-585.
37.Shiels C. and M. Gabbay (2006). "The influence of GP and patient gender interaction on the duration of certified sickness absence." Fam Pract 23(2): 246-252.
38.Shiels C. and M. B. Gabbay (2007). "Patient, clinician, and general practice factors in long-term certified sickness." Scand J Public Health 35(3): 250.
39.Shiels C., M. B. Gabbay, et al. (2004). "Patient factors associated with duration of certified sickness absence and transition to long-term incapacity." The British Journal of General Practice 54(499): 86.
40.Soderberg E. and K. Alexanderson (2005). "Sickness certificates as a basis for decisions regarding entitlement to sickness insurance benefits." Scand J Public Health 33(4): 314-320.
41.Soler J. (2003). "Sick leave certification: a unique perspective on frequency and duration of episodes-a complete record of sickness certification in a defined population of employees in Malta." BMC family practice 4(1): 2.
42.Svärdsudd L. E. K. (2000). "Sick-listing habits among general practitioners in a Swedish county." Scandinavian journal of primary health care 18(2): 81-86.
43.Swartling M., S. Peterson, et al. (2007). "Views on sick-listing practice among Swedish General Practitioners--a phenomenographic study." BMC Fam Pract 8: 44.
44.Swartling M. and R. Wahlstrom (2008). "Isolated specialist or system integrated physician--different views on sickness certification among orthopaedic surgeons: an interview study." BMC Health Serv Res 8: 273.
45.Swartling M. S., K. A. Alexanderson, et al. (2008). "Barriers to good sickness certification -- an interview study with Swedish general practitioners." Scand J Public Health 36(4): 408-414.
46.Swartling M. S., J. Hagberg, et al. (2007). "Sick-listing as a Psychosocial Work Problem: A Survey of 3997 Swedish Physicians." Journal of Occupational Rehabilitation 17(3): 398-408.
47.Thorstensson C. A., J. Mathiasson, et al. (2008). "Cooperation between gatekeepers in sickness insurance - the perspective of social insurance officers. A qualitative study." BMC Health Serv Res 8: 231.
48.Timpka T., G. Hensing, et al. (1995). "Dilemmas in sickness certification among Swedish physicians." The European Journal of Public Health 5(3): 215.
49.Upmark M., K. Borg, et al. (2007). "Gender differences in experiencing negative encounters with healthcare: a study of long-term sickness absentees." Scand J Public Health 35(6): 577-584.
50.von Knorring M., L. Sundberg, et al. (2008). "Problems in sickness certification of patients: A qualitative study on views of 26 physicians in Sweden." Scand J Prim Health Care 26(1): 22-28.
51.Walters G., K. Blakey, et al. (2009). "Junior doctors need training in sickness certification." Occupational Medicine 60(2): 152-155.
52.Watson P. J., J. Bowey, et al. (2008). "General practitioner sickness absence certification for low back pain is not directly associated with beliefs about back pain." Eur J Pain 12(3): 314-320.
53.Wynne-Jones G., C. D. Mallen, et al. (2010). "Sickness certification and the GP: what really happens in practice?" Fam Pract 27(3): 344-350.
54.Wynne-Jones G., C. D. Mallen, et al. (2010). "What do GPs feel about sickness certification? A systematic search and narrative review." Scand J Prim Health Care 28(2): 67-75.
55.Wynne-Jones G., C. D. Mallen, et al. (2009). "Identification of UK sickness certification rates, standardised for age and sex." The British Journal of General Practice 59(564): 510.