"My child is only five years old, obviously he has been diagnosed, and the insurance company is going to take a biopsy, and the biopsy is a liver cut!" On the other end of the phone, the plaintiff almost choked up......
I still remember the first time I called the plaintiff, she felt sorry for the child but couldn't do anything, and she was almost choked up when she complained angrily, and I felt that the plaintiff had pinned all the hope of the child's life on us.
A seemingly ordinary case
I have worked in the court for more than 10 years, and I have dealt with countless disputes of all kinds, large and small.
The cause of action is a common life insurance contract dispute, the defendant is an insurance company, and the plaintiff must have been denied a claim to the insurance company after suffering from some kind of illness. This kind of case is very common, and the trial mainly focuses on whether the plaintiff's illness falls within the scope of protection stipulated in the insurance contract, and whether the reason for the insurance company's refusal to pay compensation is valid.
The thoughts in my heart drifted by, I opened the file, glanced at the case file materials, and many years of experience in handling cases told me that this case is not difficult to try. Immediately arranged the court and other matters, sorted out the files stacked on the table that were almost piled up into a small mountain, and continued to write the verdict.
"Sister Qian, it's seven o'clock, why don't you pick up the baby from school?" A colleague greeted him warmly.
"Haha, today's baby dad will pick it up, and it's time for him to take responsibility."
I smiled and just finished answering, and suddenly I was stunned in my mind, realizing that I seemed to have ignored something just now, no, I quickly opened the case file stacked on it, Mom, I subconsciously exclaimed: Xiaoxiao (pseudonym) is only five years old, just entered kindergarten, and is not a few years old with my daughter!
My heart sank, and I slowly pieced together the story behind the case in combination with the dossier materials. The plaintiff was a child, four years old and seven months old, and was found to have abnormal liver function during a kindergarten physical examination a year ago, and the treatment did not heal for more than a year, and later her parents took her to a tertiary hospital in Beijing for treatment, and was diagnosed with Wilson's disease, and was hospitalized for less than a month, spending tens of thousands of yuan, and the insurance company refused to pay compensation on the grounds that the conditions for critical illness were not met.
I was not familiar with the child's disease, so I quickly checked the authoritative information. After in-depth study, it is known that Wilson's disease is a hereditary copper metabolism disorder, which is mainly manifested by liver or nervous system involvement, and serious liver or nervous system damage may occur if not treated in time, with a mortality rate of 5% to 6.1% higher than that of the general population, and lifelong follow-up treatment is required.
The child has this disease at such a young age, and the family is so anxious. As a mother, when I saw the photo of my daughter on the table, I felt mixed feelings for a while, and inexplicable emotions came to my heart.
The focus of the controversy in the trial is whether to have a biopsy
At the beginning of the trial, the two sides engaged in a heated debate about whether Xiaoxiao needed a biopsy.
The insurance company believes that although the hospital has diagnosed Xiaoxiao with Wilson's disease, the insurance contract clearly stipulates that after suffering from the disease, it is necessary to go through the liver biopsy step before it can be confirmed that it is a major disease as agreed in the insurance contract.
The plaintiff was anxious at this time, almost choked up: "Judge, do you know that the biopsy is a liver removal, and letting a five-year-old child go to the liver for a liver examination, how much damage this will do to the child's mind and body!" In order to prove that the child's condition is eligible for compensation, we have also done a genetic test, and the hospital has also issued a clear diagnosis certificate, is this not enough? The insurance company's requirement that the child must be biopsied is undoubtedly causing the five-year-old child to suffer more harm...... "I hastened to calm the plaintiff's emotions.
After several disputes, the insurance company still insisted on rejecting the claim.
The child should not be harmed again
After the trial, I returned to the office with the file in my hands with mixed feelings. Although the insurance contract stipulates that the liver biopsy is confirmed as a condition for compensation, the hospital has made a clear diagnosis after all, and the five-year-old child who has the disease must have a liver biopsy to receive compensation, which will undoubtedly cause secondary injury.
So I opened the file again, re-read the terms of the contract that I had read several times, looked at the medical records word by word, and carefully read the authoritative medical materials......
After careful screening, I found that, on the one hand, the medical professional opinion clearly stated that Wilson's disease is a copper metabolism disorder caused by a mutation in the copper transport ATPase β gene, and the clinical manifestations can include acute liver failure, corneal pigment ring, hemolysis, kidney damage, etc., and the child is undoubtedly sick. On the other hand, the liver biopsy is actually only one of the ways to diagnose the disease, not an indicator of the severity of the disease, and the insurance contract is obviously unreasonable, and the agreement is a secondary limitation on the achievement of the compensation conditions, and the insurance company has not provided evidence to remind the policyholder of the secondary limitation, so this clause has no legal effect, and the insurance company should not refuse to pay compensation.
At this point, I breathed a sigh of relief, and my heart was firm that the plaintiff's claim was reasonable, reasonable and legal, and finally ordered the insurance company to settle the claim in full according to the insurance contract.
After the judgment came into effect, I called the plaintiff's agent to ask if the insurance company had settled the claim in a timely manner and how well he had recovered. They said that the insurance company had paid for it, Xiaoxiao was in rehabilitation, and the voice of thanks came from the other end of the phone, at this time, my heart was soft and warm.
Looking back at the mental process of handling the entire case, I sincerely realized that although there will be more experience in handling more cases, only by upholding the consciousness of "everything is like me suing, and pushing myself and others in everything" can I make judgments full of legal principles more "humane" and let the people feel the temperature of the rule of law in the face of fairness and justice.
Contributed by: Xicheng Court
Editor: Liu Yuhan Shi Yang
Review: Wang Fang