Seven-year-old girl Lu Zixuan suffered from diabetes, Tianan Life Insurance refused to settle the claim, and the court favored the insurance company
Case sharing: Lu Zixuan, female, born on January 24, 2015, Han ethnicity, Xingtai City, was diagnosed with type 1 diabetes in April 2021, type 1 diabetes can not be cured, and needs to rely on insulin for life. Lu Zixuan is only seven years old, and he needs to take four injections of insulin every day to stabilize blood sugar (the child measures blood sugar every day, and the insulin injection eye becomes a sieve, which is very painful), and the monthly insulin and other costs need to be more than 1300 yuan, and with the increase of the child's age, the amount of insulin is increasing year by year, and the cost is also increasing. Parents not only need to strictly control their children's diet, but also be prepared to deal with various diabetic complications, and the economic and psychological pressure of the children's families is particularly large.
Just when the family was worried about the cost of smelting treatment, her mother Liu Xueying thought of buying The "Tianan Life Additional Auspicious Tree Lifetime Critical Illness Insurance" for her child Lu Zixuan as early as January 1, 2017, it has been five years, when buying insurance, the insurance manager also said that many major diseases can be insured, including type 1 diabetes, which brings new hope to the whole family. Mother Liu Xueying went to the insurance company on the same day to find the relevant person in charge to communicate how to settle the claim.
The result of The insurance acceptance of Lu Zixuan's type 1 diabetes by Tianan Life Insurance Company is that it is not accepted because the insurance liability of class 1 diabetes ketosis does not meet the insurance liability of minor and serious diseases of the "Tianan Life Additional Auspicious Tree Lifetime Critical Illness Insurance".
Lu Zixuan suffers from type 1 diabetes and type 1 diabetic ketosis, and the insurance company has no objection to this. According to Article 5.7.37 of the "Cheonan Life Additional Vital Illness Insurance", "Type 1 diabetes: Type 1 diabetes mellitus is characterized by a chronic increase in blood glucose due to severe insulin deficiency caused by absolute insulin secretion, and it is necessary to rely on exogenous insulin for glucose metabolism and life maintenance of the body." The insured, Lu Zixuan,1 diabetes mellitus must be definitively diagnosed, and the results of blood insulin measurement and blood C-peptide and/or urinary C-peptide determination support the diagnosis and meet all of the following conditions: 1. Have been continuously treated with exogenous insulin injections for more than 180 consecutive days; 2. Have received the following treatment as needed: (1) implanted a pacemaker due to severe arrhythmias; (2) one or more toes have been removed from or above the plantar toe knuckles due to gangrene." However, "due to need" to receive a certain treatment or surgery, the hospital decides whether to carry out the corresponding treatment or surgery according to the patient's condition, and even if the operation is carried out, the subjective consent of the insured is required. Therefore, in the understanding of "due to needs", the insurer Lu Zixuan and the insured Liu Xueying are ambiguous about this. The parties disputed the understanding of the interpretation clause of type 1 diabetes, and the court should adopt an interpretation favorable to the insured, finding that the disease she suffered was a major disease as commonly understood in accordance with the facts and the law, which was unfair to Ms. Liu Xueying, because the insurance clause was complicated, obscure and professional, and ordinary people could not understand it at all, and when the insurance company and the insured Liu Xueying signed an insurance contract, they did not inform the insured that if the insured was diagnosed with type 1 diabetes in the future, it must also be " A pacemaker is implanted, or at least one toe is removed" to settle the claim, which is clearly an "insurer exclusion clause."
According to Article 30 of the Insurance Law, "if an insurance contract concluded using the standard terms provided by the insurer is disputed between the insurer and the applicant, the insured or the beneficiary, the terms of the contract shall be interpreted in accordance with the usual understanding." Where there are two or more interpretations of the terms of the contract, the people's court or arbitration institution shall make an interpretation favorable to the insured and the beneficiary. ”
According to the Measures for the Administration of Health Insurance promulgated by the China Banking and Insurance Regulatory Commission (hereinafter referred to as the China Banking and Insurance Regulatory Commission), "Article 22 When formulating terms and conditions for medical insurance products, insurance companies shall respect the insured's right to receive reasonable medical services, and shall not set unreasonable or contrary to general medical standards in the clauses as conditions for payment of insurance premiums." Article 23 The diagnostic criteria for diseases agreed upon by insurance companies in the terms and conditions of health insurance products shall conform to the prevailing medical diagnostic standards and take into account the trend of development of medical technical conditions. After the health insurance contract takes effect, if the insured is diagnosed with a disease according to the prevailing medical diagnostic standards, the insurance company shall not refuse to pay the insurance premium on the grounds that the diagnostic standards are inconsistent with the insurance contract. ”
The Intermediate People's Court of Chifeng City, Inner Mongolia Autonomous Region, has a case exactly the same as Ms. Liu Xueying, (2018) Nei 04 Min Zhong No. 5580, and finally after the second instance, the insurance company lost the lawsuit, because the court believed that the condition had been diagnosed as type I diabetes in the hospital, and its illness was in line with the ordinary people's common understanding of such a major disease, so the insurance company argued that the appellant's illness was not within the scope of the claim, which was unreasonable, and the court did not recognize it. Other cases include the (2015) Nanmin Zhong Zi No. 904 of the Intermediate People's Court of Nanping City, Fujian Province, where the insurance company's practice of buckling words and playing routines is unreasonable and untenable.
The purpose of the critical illness insurance product is to solve the economic difficulties of the insured or his family who is seriously ill and spends a lot, so as not to seriously reduce the quality of life of the insured due to long-term treatment or huge costs of serious illness. The insured Liu Xueying also purchased serious illness insurance for Lu Zixuan based on this purpose. However, when the family needs support the most, the insurance company does not settle the claim, which not only violates the legislative purpose of the Insurance Law, but also violates the socialist core values of "fairness", "justice" and "harmony". I hope to get the attention of the society and relevant departments to save the compensation that Lu Zixuan's family should have.
Source: Weibo
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