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Data:2009-12-12 2:34
"Insurance is an equal standard contract terms reflect the most typical and most areas of concentration." Had been done two years of the insurance salesman's Li Jing, because of his experience in the hospital insurance claims for the unequal terms of format, to the Shanghai Committee of Consumer Protection complaint.
And Weiliang encountered the same Li Ching also because the insurance policy ambiguous, making his claim was rejected. Moreover, according to Shanghai Consumer Protection Committee of the statistics of complaints in this regard is rising.
Terms of the difficulties caused by vague claims
Jing purchased by the insurance company of hospital charges, insurance, in a body to the hospital for check-ups are not pregnant when the doctor was endometrial polyps need to be further diagnosed. After ambulatory surgery, postoperative pathological examination can be diagnosed only after the disease: born in the womb as benign polyps. A heart hanging down, the Li Jing to insurance claims his treatment a total of two times the medical costs of 5,000 yuan was rejected.
Materials submitted to the insurance company claims, the claims staff begin by asking what the outcome Jing pathological when that result is positive immediately said: "You all hospital expenses can only be paid by 50%, because you are a contract operation listed in the Schedule to elective surgery. "Jing is puzzled and asked:" If I were the pathological result is vicious? "claims have said that if it is malignant by 80% on the payment.
However, according to Li Jing and insurance companies signed the insurance policy liability insurance in such terms: "The insured person was hospitalized due to non-organ transplantation, in various fees within the limits, for each patient within the specified scope of the reasonable and actual expenditures the necessary bed charges, medicines, treatment costs, nursing care, inspection fees, special examination and treatment fees, ambulance fees, surgical fees and related consultation fee paid by the company's 80%. If the insured person in the policy implemented within the year in Table 3 out elective surgery, according to their actual expenses incurred by the Company 50% of the payment. Table 3 set out in a total of elective surgery, including 25 species, from the 'various types of benign tumor removal surgery' to 'chronic sinusitis and sinus radical mastectomy'. "
Li Jing was very puzzled: "The doctor gave me at the time of surgery did not know which length is malignant or benign tumors, and my insurance is a personal cost of hospitalization insurance, how can under the circumstances after surgery to determine the payment amount of it? "
According to the Consumer Protection Commission's understanding of the sea, with the increase of people buying insurance, the insured and the insurance company of various disputes between the more and more two years ago, insurance disputes were included in the China Consumer Association of China 10 big complaint hot.
Jiang's Shanghai and Shanghai Law Firm Zhou security counsel, the insurance industry itself is a need for high level of integrity, but also most vulnerable to credit crisis in the industry, the main causes of the terms of the contract and explain the problem. Zhou On the view that from a legal perspective, the insurance contract is to establish the relationship between the insurance carrier, but also the largest contract of good faith. But now insurance companies in the development of insurance contracts has often emphasized only the interests of the company, stressing the obligation of disclosure to policyholders, such as health status, age, single, etc. at the expense of insurance companies duty and obligation to inform consumers. In fact, the signing of the contract, the terms are not in express terms, insurance companies need to inform the insured of the interests involved, can not wait after Chuxian self-explanation.
The insurance contract, "the obligation of disclosure" is, etc.
Inform the insurance company stressed that the obligation to policyholders at the same time, the insurance company did not notice it seems a little bit, and insurance people (insurance companies) have to bear the corresponding notification obligation. This is in the "Insurance Law" and "Contract Law" on both provisions.
According to Supreme People's Court's "rationale insurance dispute cases on the interpretation of a number of issues", the specified insurer (insurance company) description of the obligation. "Explain" that the note refers to the insurance company obligation is entered into the insurance contract, the contract of insurance to policyholders to explain the content of the obligation.
By the High Court "interpretation" of rules: the insurer to the insured note insurance and the terms of content, should be ordinary people can understand the extent, but can be insured under the policy holders for different levels of interpretation of the experience.
"Insurance Law" under Article XVIII, on the exclusion of liability of the insurer, the insurer entering into insurance contracts should be clearly stated to the input. Here's "clear statement" means that the insurer should be in the insurance policy or his insurance certificate on exemption of liability clause can be enough to cause the insured to pay attention to tips, and should the contents of the relevant exemption clause written or oral form to policyholders to explain. And the insurer is in compliance with a clear statement of the obligation to bear the burden of proof. The safe harbor provisions of the insurance contract itself does not prove that the insurer the obligation to fulfill a note.
For the insured obligation of informing the High Court "interpretation" provides that: If the insurance is not by accident the insured failed to inform them of the major issues arising, one can assume that the matter did not inform the occurrence of insurance is not a "serious impact", the insurer shall not be insured failed to inform the ground to lift the insurance contract or not bear liability insurance.
