💴 Money, Tax & Insurance
How to Get the Most Out of Health Insurance — For Those Who Pay and Lose Out
High-Cost Medical Expense Benefit, injury and sickness allowance, lump-sum birth allowance. Your premiums work this hard for you
📖 8 min read📅 2026-08-20
The "health insurance premium" taken out of your salary every month. Have you ever thought about what it can actually be used for?
Rina (28), from Surabaya, Indonesia, was three years into working in Japan. Looking at her monthly payslip, she knew that a health insurance premium was being deducted. But she had no idea what it was useful for beyond "paying 30% at the hospital."
One day, Rina had to be hospitalized and have surgery for a sudden case of appendicitis. When she saw the bill, the blood drained from her face. "Even 30% of medical costs is this expensive?" — the amount presented at the counter would take a big bite out of her savings.
But then a senior colleague at work told her this: "Rina, there's a system called the High-Cost Medical Expense Benefit. There's a cap on your out-of-pocket cost for one month. And you might also get part of your income back through the injury and sickness allowance for the time you took off for the hospital stay. Did you apply?"
Rina didn't know. She didn't know that the premiums she paid every month were precisely for moments like this. When she did the procedures, her medical costs came back down to the cap, and she also received an allowance for the period she took off. "I was just paying — I never knew how to receive," she told us.
Health insurance is not only for the hospital counter. There are several benefits you lose out on if you don't know about them. Here is a checklist for "getting the most out of" your premiums.
Health insurance (the employees' insurance that company workers join) has benefits that ease your medical-cost burden and benefits that support your income while you can't work. Foreign nationals can use them in the same way, as long as they are insured members (the insured). Use the list below to check the rights you can use.
01.Your out-of-pocket share of medical costs is, in principle, 30%. Start with this basic fact
If you show your health insurance card (or My Number insurance card) at the hospital, your out-of-pocket share of medical costs is, in principle, 30% (ages 6–69). Insurance covers the remaining 70%. Put the other way around, if you forget your insurance card, you pay the full amount (100%) at the counter for the time being (you can apply for a refund later). Foreign nationals, too, pay exactly the same 30% as Japanese people if they are enrolled in the company's health insurance.
02.[Most important] High-Cost Medical Expense Benefit — there is a "cap" on your out-of-pocket cost for one month
Even if medical costs become large due to hospitalization or surgery, **there is a cap on your out-of-pocket cost for one month (within the same calendar month) according to your income, and anything above it is refunded** (the High-Cost Medical Expense Benefit). The cap is set by income bracket. **Note: this cap is being raised and revised in stages starting in August 2026.** For your exact cap, check the latest guidance from the health insurance you are enrolled in (Kyokai-kenpo or a health insurance association). The tip for the procedure is in the next item.
03.With a "Certificate of Limit Amount Applicability" or a My Number insurance card, keep your counter payment within the cap from the start
The High-Cost Medical Expense Benefit can be received as a "later refund," but paying a large amount up front is hard. **If you prepare a "Certificate of Limit Amount Applicability" in advance and present it at the hospital, or use a My Number insurance card, you can keep your counter payment within that month's cap from the start** (and the later application becomes unnecessary too). Once hospitalization is decided, contact your health insurance early to say "I'd like a Certificate of Limit Amount Applicability," or check with the hospital whether you can use a My Number insurance card.
04.Injury and sickness allowance — supports your income while you can't work due to illness or injury
When you take time off work due to a non-work-related illness or injury and receive no salary, **you can receive the "injury and sickness allowance" for the period off from the 4th day onward** (the first three consecutive days are a waiting period). The amount is roughly **two-thirds of your salary (standard daily remuneration).** It is paid for a combined total of up to **1 year and 6 months.** You can apply yourself without going through the company, and insured foreign nationals are also eligible. "Can't work" does not mean "zero income." Be sure to check this when you need long-term medical treatment.
05.Lump-sum birth allowance — in principle 500,000 yen for childbirth
When a health insurance member (or their dependent) gives birth, a "lump-sum birth allowance" of **in principle 500,000 yen per child** is paid (since April 2023, for deliveries covered by the Obstetric Compensation System). In many cases it is paid directly to the hospital (the direct payment system), greatly reducing your burden at the counter. Furthermore, if the member herself is enrolled in the company's health insurance and takes time off before and after childbirth, she can also receive a "maternity allowance" equal to about two-thirds of her salary. Childbirth is covered for foreign nationals in the same way.
06.Overseas medical expenses — part of sudden treatment during a temporary return home comes back too
If, while you are away from Japan (such as during a temporary return home), you receive treatment at a local medical institution for a sudden illness or injury, **you can apply and get part of the medical cost refunded** (overseas medical expenses). The refund is calculated based on "what the same treatment would cost under insurance coverage in Japan." Note: treatment not recognized under Japanese insurance (such as cosmetic surgery), or travel for the purpose of treatment from the start, is not covered. The application requires the local statement of treatment details and the receipt (with a Japanese translation), so keep them rather than throwing them away. The statute of limitations is 2 years.
07.Your family's (dependents') medical costs are covered too
The medical costs of family members who are your dependents are also covered by health insurance (family medical benefit; in principle 30% out of pocket). There is also a "family lump-sum birth allowance" when a family member gives birth. But note: the injury and sickness allowance and the maternity allowance are benefits that "make up for the income of the working member," so they are not paid to dependents (family members who are not working). What is covered for family members is medical costs and the lump-sum birth allowance.
For Rina, the High-Cost Medical Expense Benefit brought her medical costs back down to the cap, and the injury and sickness allowance made up for her income during the time she took off. She told us she truly felt that her monthly premiums were there for moments like this. Many health insurance benefits are ones you "apply for yourself," and you can't receive them if you don't know about them. You can check the content and amounts of benefits on the website of the Kyokai-kenpo or health insurance association you belong to, or with your company's general affairs or HR department. Because the High-Cost Medical Expense Benefit cap changes from August 2026 onward, always confirm the latest amount before being hospitalized.
