Article 22
After the occurrence of an insured event, when requesting compensation or payment of insurance money from the insurer in accordance with the insurance contract, the policyholder, the insured or the beneficiary shall provide the insurer with the relevant proofs and materials that it can provide to confirm the nature, cause and extent of loss of the insured event.
If the insurer finds that the relevant certificates and materials are incomplete in accordance with the provisions of the contract, it shall promptly notify the policyholder, the insured or the beneficiary to provide supplementary information in a one-time manner.
Interpretation of Provisions
1. The main purpose of this article
This article is about the obligation to provide information to prove the loss claimed.
II. Evolution of the Provisions
Article 22 of the Insurance Law, promulgated and implemented in 1995, stipulates that: "After the occurrence of an insured event, when the insurer is requested to compensate or pay insurance money in accordance with the insurance contract, the policyholder, the insured or the beneficiary shall provide the insurer with the certificates and materials that it can provide to confirm the nature, cause and extent of loss of the insured event." If the insurer finds that the relevant certificates and materials are incomplete in accordance with the provisions of the insurance contract, it shall notify the policyholder, the insured or the beneficiary to provide additional relevant certificates and materials. When the Insurance Law was amended in 2002, the content did not change, except that the order of the articles was adjusted to Article 23. During the implementation of the Insurance Law, it often happens that insurers take advantage of loopholes in the law to create obstacles for policyholders, insureds and beneficiaries to apply for compensation. For example, in order to deliberately delay the time for compensation, some insurers repeatedly ask the policyholder, the insured, and the beneficiary to provide supplementary information; Some insurers deliberately delay time under the pretext of incomplete information after the policyholder, insured, or beneficiary submit the information; There are also insurers who ask policyholders, insureds, and beneficiaries to provide information that they cannot provide.
In response to this phenomenon, when the Insurance Law was amended in 2009, on the basis of retaining the obligation to provide proof and information of the insured accident to the policyholder, the insured or the beneficiary, the obligation to "give a one-time notice in a timely manner" was added to the insurer if supplementary materials are required. In this regard, there was controversy in the process of amending the Insurance Law in 2009, and some people suggested that the "one-time" requirement should be abolished, because in practice, the required proof and materials for certain major and complex cases, especially those involving litigation, will also change with the development of the case, and the insurer cannot meet the "one-time notice" requirement. However, in order to better protect the interests of the policyholder and avoid the occurrence of the situation where the insurer delays the settlement of claims for any reason, the legislator still chose to add this provision.
In the 2009 draft amendment to the Insurance Law, there was a provision that "if the insurer considers that the relevant certificates and materials are incomplete in accordance with the provisions of the insurance contract, it shall promptly notify the policyholder, the insured or the beneficiary in writing to provide supplementary information in a timely manner", but it was opposed because: (1) in practice, the stage at which the insurance company notifies the supplementary materials is relatively flexible, for example, the supplementary materials can be notified when the site is investigated: the timeliness of the one-time written notice is poor. The insurance company may wait for all the information to be sorted out before collecting the written notice, which will delay the time and is not conducive to the rapid settlement of claims. (2) Written notices increase the number of written documents and the delivery process, making the claim process more cumbersome. Therefore, whether in written or oral form, the insurer only needs to notify the policyholder, the insured or the beneficiary in a timely and one-time manner in accordance with the contract.
When the Insurance Law was amended in 2009, in addition to the above adjustments, the serial number of the article was also changed to Article 22. Since then, when the Insurance Law was amended in 2014 and 2015, the content and serial number of this article have not been amended, and they are still in use today.
3. Interpretation of Provisions
This article contains two parts: one is the obligation of the policyholder, the insured or the beneficiary to provide proof and information of the insured event; The second is the obligation of the insurer to notify the policyholder, the insured or the beneficiary of supplementary materials. The obligation of the policyholder, the insured or the beneficiary to provide proof and information of the insured accident means that after the occurrence of the insured event, in order to request compensation or payment of insurance money from the insurer, the policyholder, the insured or the beneficiary has the obligation to provide the insurer with the proof and information related to the confirmation of the nature, cause and extent of loss of the insured accident. The insurer's obligation to notify and supplement means that if the insurer considers that the relevant certificates and materials are incomplete in accordance with the contract, it shall promptly notify the policyholder, the insured or the beneficiary to provide supplementary information in a one-time manner.
(1) The obligation of the policyholder, the insured or the beneficiary to provide proof and information of the insured accident
The first is that the obligation arises in the insurance claim process. Insurance claim refers to the act of the policyholder, the insured or the beneficiary requesting compensation or payment of insurance money from the insurer in accordance with the provisions of the insurance contract after the occurrence of the insured event. After the occurrence of an insured event, the policyholder, the insured or the beneficiary needs to prove that there is an insurance contract relationship between the policyholder, the insured or the beneficiary in order to obtain the insurance compensation, and that the insured accident agreed in the insurance contract has occurred and caused losses to it, which is the premise of the insurance claim.
Second, the policyholder, the insured or the beneficiary shall provide the insurer with relevant certificates and materials related to confirming the nature, cause and extent of loss of the insured event. According to the provisions of this article, the information and proof provided by the policyholder must be related to the confirmation of the nature, cause, and degree of loss of the insured accident, and the policyholder has the right to refuse to provide it if it exceeds the scope. The "relevant certificates and materials" mentioned here mainly refer to: (1) the original of the insurance policy or insurance certificate; (2) Proof of payment of insurance premiums; (3) Account books, receipts, invoices, packing lists, transportation contracts and other original documents related to insured property; (4) ID card, work permit, household registration booklet or other supporting materials related to the name, age, occupation and other circumstances of the insured person of life insurance; (5) Certificates and materials confirming the nature, cause, and extent of loss of the insured accident, such as investigation and inspection reports, insurance certificates, damage appraisals, death certificates of the insured, appraisals of the degree of incapacity for work, and conclusive opinions on liability cases; (6) A list of claims, such as a list of damaged property, a list of various expenses, and a detailed list of other claims required from the insurer. In insurance practice, most insurance contracts will set out the certificates and materials to be provided by the policyholder, the insured and the beneficiary.
Third, the provision of information and proof must be limited to what the policyholder, the insured and the beneficiary can provide. The certificate and information required by the insurer to be provided by the policyholder shall not exceed the capabilities of the policyholder, the insured and the beneficiary. This obligation is based on the premise that the policyholder has an advantage in possessing information about the occurrence of the insured event, and it is not necessary to provide some certificates and materials if it is difficult or even impossible for the policyholder to obtain. The above two restrictions are attached to this obligation in order to prevent the insurer from abusing its right to refuse to pay on the pretext that the information provided by the policyholder is incomplete.
(2) The insurer's obligation to notify the supplementary materials in a timely and one-time manner
According to the provisions of paragraph 1 of this article, the policyholder, the insured or the beneficiary shall provide proof and materials of the insured event, and if the insurer considers that the relevant certificates and materials are incomplete in accordance with the contract, it shall not refuse to pay compensation on this ground, but shall notify the policyholder, the insured or the beneficiary to provide a one-time supplement. The ultimate purpose of insurance is to be compensated in the event of damage, therefore, the success of the claim depends on timely informing the insurer of the time, place and cause of the occurrence of the insured event, as well as the number of the relevant insurance documents, the subject matter of the insurance, the duration of the insurance, etc., and in particular, the insurer shall be provided with the relevant certificates and information that it can provide to confirm the nature, cause and extent of the insured event, and these certificates and information shall be true, accurate and complete. If the insurer believes that the relevant certificates and materials provided by the policyholder, the insured or the beneficiary are incomplete in accordance with the provisions of the insurance contract, it shall promptly notify and supplement the information in a one-time manner, so as to facilitate the insurer to quickly investigate, verify and confirm the insured accident and do a good job in settling claims.
Although there is controversy over the addition of "timely one-time notice" when the Insurance Law was amended in 2009, most insurance contracts have clear provisions on the proof and materials that the policyholder needs to provide, so it is not difficult for the insurer to determine whether the information provided by the policyholder is in accordance with the contract. The law requires the insurer to notify the policyholder in a timely and one-time manner to provide supplementary materials, which is not too strict. As for some major and complex insured accidents, if the proof and materials required by the policyholder for loss assessment and claim change with the situation and exceed the provisions of the insurance contract, it is not subject to the "one-time" constraint, and the insurer may still require the policyholder to provide it if it deems it necessary and within a reasonable range.
Applicable Guidelines
This article stipulates the obligation of the policyholder to provide proof and information of the insured event, but does not stipulate the legal consequences of violating this obligation. In insurance practice, many insurance contracts stipulate that if the insurer fails to provide the proof and materials agreed in the contract, the insurer has the right to terminate the contract or be exempted from paying insurance benefits. What is the effect of such clauses? In this regard, we believe that it should be treated differently on a case-by-case basis.
1. The insurer cannot terminate the insurance contract or refuse to compensate solely on the grounds that the policyholder fails to provide relevant certificates and materials as agreed in the contract
Some scholars believe that after the occurrence of an insured event, the reason for the existence of the obligation to provide information or inform is nothing more than to enable the insurer to correctly estimate the scope of damage and determine the cause of the accident, or to grasp the time to protect its legal interests. Therefore, if the policyholder or the insured fails to provide or inform the relevant information within the agreed time limit, the insurer may not terminate the contract or claim that it is not liable for insurance compensation, but can only claim compensation for the damages arising therefrom. [2] In the United States, the standard for judging whether an insurance policy has been performed is relatively relaxed, and courts everywhere insist on using the standard of "substantial performance" to determine whether the proof of loss is sufficient. If the insured is unable to submit proof of loss, the court's attitude at this time is the same as the attitude towards the notification obligation, and the insurer will not be allowed to refuse to pay on this ground.
We agree with the above viewpoint, the law stipulates that the policyholder has the obligation to provide proof and information of the insured event after the occurrence of the insured event, so as to enable the insurer to timely and accurately investigate and assess the damage and preserve the evidence. Its legislative purpose is similar to the obligation to notify of an accident under article 22 of the Insurance Law. Therefore, even if the policyholder fails to provide proof and materials in accordance with the insurance contract, as long as it does not affect the determination of the cause, nature and degree of loss of the insured event, the policyholder should still be compensated, and the insurer cannot terminate the contract or refuse to pay compensation on this ground.
However, if the nature, cause, and loss of the insured accident cannot be determined due to the policyholder's failure to provide complete information, the insurer shall be deemed to have failed to fulfill the burden of proof, and the insurer may refuse to pay, but the scope of its refusal to pay compensation is limited to the part of the loss that cannot be determined, and the part of the loss that can be determined shall still be compensated. Even if there is a standard clause in the insurance contract similar to "if the policyholder fails to provide the proof and materials agreed in the contract, the insurer has the right to terminate the contract or be exempted from paying the insurance money", the policyholder may claim that the clause is invalid in accordance with the provisions of Article 19 of the Insurance Law on invalid standard clauses.
2. If the policyholder, the insured or the beneficiary provides false certificates and information, it shall be regarded as insurance fraud
There are two main situations: one is that the insured accident does not occur, and the policyholder, the insured or the beneficiary provides false certificates and materials to falsely claim that the insured accident has occurred. In such a case, the insurer has the right to terminate the contract without a refund of the insurance premium, in accordance with paragraph 1 of article 27 of the Insurance Act. Second, after the occurrence of an insured event, the policyholder, the insured or the beneficiary fabricates the cause of the insured accident or exaggerates the extent of the loss by forging or altering the relevant supporting materials in an attempt to obtain excess compensation. In such a case, the insurer shall not be liable for compensation or payment of insurance money for the part falsely declared, and if the insurer pays the insurance money or expenses as a result, it shall return or compensate.
In summary, the breach of the obligation of the policyholder to provide proof and information of the insured event under different circumstances will have different legal consequences, which is not only in line with the original intent of the legislation, but also can be connected with other provisions of the Insurance Law, and can better balance the interests of both parties.