Serious illness hospitalization surgery, 200,000 insured amount of serious illness insurance refusal, the court ruled

The purchase of serious illness insurance was intended to escort health, and after diagnosis, insurance benefits could be obtained in time, but the insurance company refused to perform its compensation obligation on the grounds that it "did not meet the conditions for insurance payment". The Guangzhou Intermediate People's Court held that the "disease interpretation" clause in the insurance contract deviated from the usual cognition and common diagnosis and treatment standards, and should be regarded as an exemption clause, and ordered an insurance company to pay the insurance premium of 70,000 yuan to the insured and exempt the insurance premium for subsequent periods.

After falling ill, he was refused compensation

Xiao Wen signed a "Major Illness Insurance Contract" with an insurance company, and the basic sum insured was 200,000 yuan. Among them, the "minor illness insurance benefit" stipulates that if the insured is diagnosed with one or more minor diseases for the first time in an approved hospital after the waiting period, the insurance company will pay the beneficiary a certain proportion of the basic sum insured of this contract to the beneficiary for mild illness insurance; the interpretation of "vena cava filter implantation" in mild diseases is: "Vena cava filter implantation refers to the need to undergo surgical implantation of vena cava filter after the specialist of the approved hospital proves that there are repeated pulmonary embolism attacks and anticoagulation treatment is ineffective". The interpretive content is highlighted without bolding or bolding.

After the waiting period, Xiao Wen, who was about 8 weeks pregnant, went to a hospital in Qingyuan for deep vein thrombosis of his left lower extremity, and the hospital issued a "Notice of Critical Illness and Serious Illness".

The next day, Xiao Wen was transferred to a third-class public hospital in Guangzhou for hospitalization; the hospital believed that Xiao Wen had indications for surgery and that complications such as acute pulmonary embolism might occur, and after communication and explanation, Xiao Wen said that he would give up the fetus and actively carry out surgical treatment. The hospital performed "inferior vena cava angiography + left iliac veinography + left lower extremity venography + inferior vena cava filter implantation + catheter thrombolysis".

Xiao Wen applied for a claim to an insurance company, and an insurance company refused to pay the insurance premium on the grounds that "this application does not meet the conditions for the payment of insurance premiums stipulated in the Terms of Major Illness Insurance".

After trial, the Guangzhou Intermediate People's Court ruled that an insurance company should pay Xiaowen an insurance premium of 70,000 yuan and waive the insurance premiums for subsequent periods.

Reason for adjudication: The disease interpretation clause deviates from the usual cognition and common standards of diagnosis and treatment should be regarded as a disclaimer clause

Pulmonary embolism is a disease with a high fatality rate, and the purpose of vena cava filter implantation is to intercept the detachment of venous thrombus in the limb, prevent it from entering the pulmonary circulation, and prevent the resulting pulmonary embolism.

The insurance clause in question limited vena cava filter implantation to repeated pulmonary embolism attacks and ineffective anticoagulation therapy, which does not meet the clinical application criteria of vena cava filter implantation and will also undermine the insured's right to receive reasonable medical services.

Moreover, the type of disease covered by the insurance company is an important consideration for the insured when applying for sickness insurance. Vena cava filter implantation is one of the diseases covered by an insurance company, and the insured naturally believes that he or she can be compensated after receiving vena cava filter implantation. However, the insurance clause involved in the case limited the scope of the claim for vena cava filter implantation beyond the reasonable prediction of the average person at the time of entering into the contract.

Since the above-mentioned disease interpretation clause greatly limits the clinical application scope of vena cava filter implantation, deviates from the usual cognition and common diagnosis and treatment standards of the average person, and actually exempts or reduces the insurance liability of the insurer, it should be regarded as an exemption clause. An insurance company should fulfill the obligation of reminder to the insured in this regard.

However, the insurance contract involved in the case only concluded the above-mentioned disease interpretation clause in the insurance contract as an ordinary insurance clause, and it was not highlighted, which was not enough to attract the attention of the insured, and an insurance company did not explain the concept, content and legal consequences of the definition to the insured that ordinary people can understand. According to Article 496 of the Civil Code of the People's Republic of China, the above-mentioned disease interpretation clause does not become the content of the insurance contract and has no effect on Xiaowen.

In summary, the vena cava filter implantation received by Xiao Wen is a mild disease stipulated in the insurance contract, and an insurance company should pay the insurance premium. The insurance contract stipulates that the basic sum insured is 200,000 yuan, and the proportion of this payment is 35%, so the amount of insurance premium that an insurance company should pay to Xiaowen is 70,000 yuan.

The judge said: The insurance company's failure to fulfill the obligation to indicate the "disease interpretation" clause cannot become the content of the insurance contract

Critical illness insurance is one of the types of insurance commonly insured by consumers. In insurance practice, insurance companies will expand the types of insured diseases as much as possible based on the consideration of enhancing the competitiveness of the industry and attracting consumers to apply for insurance, and based on the consideration of risk control, there are cases where the scope of claims for insured diseases is narrowed through "disease interpretation".

As a result, there is a huge gap between the insurance company's professional understanding of the insurance contract and the reasonable expectations of the insured and the insured for the insurance contract, and contradictions and disputes occur from time to time. Some critical illness insurance products are so harsh that the scope of claims for certain covered diseases is so harsh that the insured person cannot actually get the protection it deserves, and the relevant illness insurance clauses have become "zombie clauses" that "protect the dead and not protect the life", which is criticized by consumers.

The "definition of sickness" in critical illness insurance is the definition of insurance liability, which is crucial to the conclusion of insurance contracts. The "definition of disease" clause in the insurance contract deviates from the usual cognition of the average person and the common diagnosis and treatment standards, limits the scope of claims for diseases, and actually exempts or reduces the insurance liability of the insurer, which should be regarded as an exemption clause, and the insurance company should perform the obligation of prompting and explaining to the insured, so that the insured fully understands the scope of liability of the major illness insurance it is insured, and on this basis, makes a true expression of intention to apply for insurance. Otherwise, the relevant "disease interpretation" clause cannot become the content of the insurance contract, and it will not be effective against the insured, and the insurance company cannot claim exemption from compensation liability on this basis.

Text/Guangzhou Daily, Xinhuacheng Reporter: Wei Lina Correspondent: Zhang Yahui, Li Jie, Duan Jingnan

Photo/ Guangzhou Daily, Xinhuacheng Reporter: Chen Youzi

Guangzhou Daily New Flower City Editor: Zhang Ying