If the treatment method does not conform to the contract, can the insurance company refuse to pay the claim? Let's take a look at the case!
Poke the audio, and the anchor will reveal it for you......
Typical cases
In May 2007, Mr. Li purchased an adult lifelong critical illness insurance policy from a life insurance company and signed an insurance contract. In October 2022, Li was admitted to the hospital with sudden epigastric pain and was diagnosed with type B aortic dissection, grade 3 hypertension, hypoproteinemia, bilateral pleural effusion, and liver cyst. In November 2022, the hospital performed aortogram, endovascular isolation of aortic stent graft, coronary angiography with single catheter, and subclavian artery stent implantation for Li.
After recovering from illness and being discharged from the hospital, Li requested insurance claims from the life insurance company, but the insurance company refused to pay compensation on the grounds that it was not a critical illness insurance liability under the insurance contract. After the two parties coordinated to no avail, Li filed a lawsuit with the court.
After trial, the court held that the insurance contract involved in the case clearly stipulated that the insurance coverage of major diseases included "aortic surgery", and at the same time, it was further clarified that aortic surgery refers to the actual operation of resection, replacement and repair of diseased aortic vessels carried out by thoracotomy or laparotomy for the treatment of aortic diseases. In terms of interpretation, "treatment of aortic disease" is the goal, while "thoracotomy or laparotomy excision, replacement, and repair" is the method of treatment.
Plaintiff Li was insured in 2007, and it has been 15 years since the occurrence of this insurance accident, and the current medical technology has made great progress compared with 2007, and many traditional, destructive, and side effects of medical methods have been replaced by new medical technology means that are safer, less invasive, and more efficient. For the insured, when they suffer from a critical illness, they often choose a treatment method with less trauma and low mortality rate based on their own physical condition so that their disease can be effectively treated, and will not adopt the treatment method limited by the insurer in order to ensure the payment of critical illness insurance benefits. Therefore, it was decided in accordance with the law that the defendant life insurance company should pay the corresponding insurance money to the plaintiff Li.
Sha anchor said
The Civil Code stipulates that in the process of performing a contract, the parties shall avoid wasting resources, polluting the environment and damaging the ecology. As far as this case is concerned, if it is simply and mechanically interpreted in isolation according to the insurance contract of 15 years ago, it will inevitably lead to the inability of patients to enjoy advanced and effective medical technology, resulting in a waste of medical resources, and it is also obviously contrary to the original intention and purpose of the contract signed by the parties. The purpose of the policyholder's purchase of life insurance is to reduce the risk in the event of an accident or illness, and when the insurance contract clearly stipulates that the insured's illness meets the conditions for claims, the defendant's refusal to settle the claim on the grounds that the medical treatment chosen by the plaintiff does not conform to the provisions of the insurance contract not only defeats the purpose of the contract between the parties, but is also not conducive to the protection of the insured's interests.
Links to legal provisions
Civil Code of the People's Republic of China
Article 509:The parties shall fully perform their obligations in accordance with the agreement.
The parties shall follow the principle of good faith and perform obligations such as notification, assistance, and confidentiality in accordance with the nature, purpose, and transaction habits of the contract.
In the process of performing the contract, the parties shall avoid wasting resources, polluting the environment and damaging the ecology.
Reporter: Chang Junqing, Wang Sha