95.9% of Japanese Care Facilities Require a Signature Other Than the Resident's — What the Law Forbids Is Refusal on the Sole Ground of Absence, Not the Asking

Japanese care facilities are barred from turning people away. Article 4-2 of the ministerial standards on staffing, facilities and operation of designated nursing homes[1] provides that a facility may not refuse to provide services without proper cause. For hospitals, Article 19(1) of the Medical Practitioners Act[1] provides that a doctor may not refuse examination or treatment without proper cause.

Having no guarantor does not amount to proper cause. The ministry has said so in its national briefings for local authority directors.

Practice has not moved. The survey report compiled by the Administrative Evaluation Bureau puts it plainly.

Facilities requiring a signature other than the person's own at the point of admission account for 95.9%

That 95.9% comes from a study carried out in fiscal 2017 under a ministry health promotion programme, quoted in the 2023 report. The medical side is the same. The report cites a ministry survey in which more than 60% of responding medical institutions required a guarantor on admission[1]. In a survey by the Kanto Regional Administrative Evaluation Bureau in March 2022, which was not nationwide, more than 90% of responding hospitals and care facilities[1] required one.

Facilities are asking for two roles

What are facilities actually asking for? The report sorts it into two. One is avoiding the risk of unpaid bills beyond what the person can cover. The other is protection of personal welfare and management of assets once capacity declines.

So what is wanted is someone to cover a missed payment and someone to decide on the person's behalf. The first is money; the second overlaps with what adult guardianship is for. From the facility's side, both are things to hand to one person standing in for family.

Local authorities have said that guarantors are sought to avoid unpaid fees, the absence of anyone to handle daily needs after admission, and uncertainty about emergencies. The reasoning on the ground holds together.

6.717 million households of older people living alone

The report gives the scale of the demand. According to the 2020 Population Census, single-person households aged 65 and over numbered 6.717 million, and older people without family or relatives are thought to be increasing[2].

Living alone does not by itself mean having nobody. But the number of people with no one nearby to sign at the point of admission sits at that order of magnitude.

The survey identified 412 operators

A private sector has emerged to meet the demand, bundling guarantor services, daily living support and post-death arrangements.

The survey set out to map it. It covered 34 municipalities, 135 community general support centres, 34 consumer affairs centres and 204 operators providing these services, between August 2022 and July 2023[2].

On the operator side: 412 operators were identified in total, of which 88 agreed to interview surveys, with a written survey requested of the remaining 319[2].

There is no supervising ministry and no industry body

Then the report sets out the nature of the sector.

Cases have arisen of such operators going bankrupt, and other problems with users have occurred, yet nothing has established the state of the sector as a whole; there is no ministry supervising it and no association to which multiple operators belong, so it cannot be said that adequate measures have been taken[2].

No governing law, no supervising ministry, no industry body. The survey itself exists because nobody knew the shape of it.

Support with decision-making is contracted at the same time

The contracts overlap too. Of the 88 operators interviewed, 67 conclude a voluntary guardianship contract at the same time as a contract delegating asset management, in case the person's capacity becomes insufficient[2].

Sixty-seven of 88 is 76.1%. Asking for a guarantor hands the same party the power to decide once capacity goes.

What is forbidden is refusing, not asking

Why does the law exist while practice does not move? Read how the prohibition is written.

What the provisions forbid is refusal. The Medical Practitioners Act says a doctor may not refuse; the ministerial standard says provision may not be refused. The guidance that the absence of a guarantor is not a legitimate reason for refusal follows from the same wording.

Asking, on the other hand, is not forbidden. A facility requiring a signature other than the person's own at the point of application is not, in itself, unlawful. Anyone asked and unable to comply simply cannot proceed. Nobody was refused, so nothing is recorded as a refusal.

That gap does the work. Because the prohibition attaches to refusal, an outcome, the act of asking that precedes it sits outside the system. Practice stops before the line; the law looks only at what happens after it. 95.9% is the size of that gap.

The same shape appeared in fair costs in trucking（このサイトの記事）. What is forbidden is contracting at an unreasonably low rate, while subcontracting itself is not, so layered subcontracting survived. Where the prohibition is placed decides whether it reaches practice.

77.0% of the money is paid up front

Look at the receiving side and the flow of money has a shape.

Of the 204 operators surveyed, 157 (77.0%) reported holding deposits, so collecting fees ahead of delivering the service, mainly after the person's death, appears to be standard practice[2].

A deposit here means the cost of services used mainly after death, paid in advance to the operator or to a corporation partnered with it[2] — funerals, interment, grave maintenance.

The service arrives after death; the money is paid while alive. Years pass between the contract and its performance.

Nothing in law governs how that money is held

How is the money held? Deposits are managed in the operator's own dedicated account by 108 operators (68.8%), in an account other than the operator's own excluding trust accounts by 33 (21.0%), and in a trust company's trust account by 29 (18.5%)[2].

Close to seven in ten sit in the operator's own account. Looking at individual answers, among those reporting management in their own dedicated account, one operator holds the money as cash in a safe on its premises, and one holds it in an account in the personal name of the representative director[2].

What has happened before is recorded too. In the past, an operator held deposits without safeguards, went bankrupt, and neither the service nor the deposit was returned; since then, nothing in law regulates how deposits in this sector are held[2].

Money has already been lost this way, and there is still no rule. The report sets both sentences down as fact.

Some money comes back and some does not

What happens on cancellation splits in two.

Deposits are consistent. All 69 operators holding deposits for post-death services return them in full less fees, with 68 (98.6%) setting this out in the contract and one (1.4%) in the statement of important matters[2].

The split is elsewhere. Among the 88 operators interviewed, 66 collect an entrance or contract fee from users, a charge that is not payment for a service but effectively a fee for the right to receive one[2].

Those fees are treated differently by different operators, with some returning nothing and some returning part[2]. One contract quoted in the report provides that if the contract ends within one year of conclusion, 80% of the entrance fee is returned, with the rate falling by 20 points for each further year, and nothing returned if it ends after four years[2].

A qualified consumer organisation has sought an injunction

It has reached litigation. One operator told a user seeking cancellation that the entrance fee would not be returned under its terms, and was met with an injunction claim from a qualified consumer organisation asserting that the fee and its non-return clause were void under Article 10 of the Consumer Contract Act[2].

What followed is recorded as well. The operator revised the clause, lowered the entrance fee and broke it into four components (initial costs, guarantor support, money management support and post-death support), after which the same organisation stated that the revised partial non-return clause was equally void and that the four components had no substance[2].

Whether money may be kept at all is itself being litigated.

The report also offers a comparison: fee-charging homes for older people operate a cooling-off arrangement known as the 90-day rule for returning entrance lump sums, which may serve as a reference[2].

The most important terms are not being explained

How much is explained before signing? Among matters considered particular to this sector, those recorded in the statement of important matters were: how deposits are managed, 11 operators (39.3%); indication of wishes on surgery and life-prolonging treatment, 10 (35.7%); protection of personal data, 10 (35.7%); cooperation with heir searches, 9 (32.1%); response to emergency contact, 5 (17.9%); and recourse where a debt has been guaranteed, 2 (7.1%)[2].

How the prepaid money is held appears in 39.3% of statements. Wishes on surgery and life-prolonging treatment appear in 35.7%. The items that matter most in the situation where a guarantor is needed are the ones missing from the paperwork.

The contracting party is an older person whose capacity is declining

Set the conditions out together. The person contracting is old and their capacity will decline. The contract runs past their death. Services and fee headings differ by operator, so comparison is hard. Part of the money is paid in advance and nothing in law governs how it is held. Entrance fees may not come back.

As consumer protection, the terms are poor. The report itself notes that comparing operators is difficult and that the portion of a deposit representing the operator's remuneration is not separated from actual costs.

Government has moved somewhat. On 30 July 2025 the Ministry of Health, Labour and Welfare partially revised its notice on how municipalities and community general support centres should handle enquiries about these services. That is work on the enquiry desk.

While facilities keep asking, the demand does not go away

The entrance has not changed. While facilities keep asking, demand for these services does not go away.

The need to count provision and reach separately is the structure covered in exclusion and non-take-up（このサイトの記事）. Here, an act the law does not touch sits in front of the stage where reach begins.

Support with decision-making enters through a bank counter, as 93.4% of adult guardianship applications are filed to manage or close an account（このサイトの記事） showed. Everyday guaranteeing enters through a facility's counter. For the person concerned both arrive at once; the systems sit apart.

And on the guardianship side, 67 of the 88 operators conclude a voluntary guardianship contract at the same time[2]. Two entrances, and the parties who take them on converge into one.

What has to be counted before the next decision

What is known is the number of operators, the content of contracts and how deposits are held. Two things are missing.

The first is how many people were asked for a signature and could not produce one. The 95.9% figure covers facilities asking. How many people were asked, and how many of them failed to gain admission, is unknown. Since nothing is recorded as a refusal, there is nothing to count.

The second is whether contracts are performed after the user dies. More than 70% of the 79 operators whose post-death contracts were obtained include a provision for reporting performance to heirs or letting heirs verify it[2], but where there are no heirs, nobody is designated to check. The person who paid in advance cannot see it done.

Further Reading

• 『成年後見の社会学』 (The Sociology of Adult Guardianship)（外部サイト、新しいタブで開きます） (Shinya Saisho, Keiso Shobo). A study based on interviews into who carries property management and rights protection for people with impaired capacity. Useful for examining the gap between what facilities ask for and what the system covers.

References

Survey on Advancing Consumer Protection in Guarantor-Support Businesses for Older People: Results Report — Administrative Evaluation Bureau, Ministry of Internal Affairs and Communications (2023). Ministry of Internal Affairs and Communications

Survey on Advancing Consumer Protection in Guarantor-Support Businesses for Older People: Notice Based on the Findings — Ministry of Internal Affairs and Communications (2023). Ministry of Internal Affairs and Communications

Partial Amendment to the Notice on Handling Enquiries about Guarantor-Support Businesses at Municipalities and Community Care Centres (Long-Term Care Insurance Update Vol.1409) — Ministry of Health, Labour and Welfare, Health and Welfare Bureau for the Elderly (2025). Welfare and Medical Service Agency, WAM NET

Survey on Guarantors for Older People: Focusing on Cases of Support for Hospital and Facility Admission — Kanto Regional Administrative Evaluation Bureau, Ministry of Internal Affairs and Communications (2022). Ministry of Internal Affairs and Communications