Source: Faxin
Transferred from: Faxin
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1. The standard terms of the insurance contract that limit the treatment method when the insured person is ill are invalid, and the insurer shall not refuse to settle the claim because the insured has not chosen the treatment method specified in the insurance contract -- Wang Yuguo v. Chinese Life Insurance Company Huai'an Chuzhou Branch Insurance Contract Dispute Case
Gist of the case: The insurance company's use of the standard terms of the insurance contract to limit the treatment method of the insured when he is ill is not in line with the medical law, nor is it contrary to the purpose of signing the insurance contract. The insured has the right to choose the best treatment method according to his or her own condition, without being restricted by the insurance contract. The insurance company cannot exempt the insured from its insurance liability on the ground that the insured has not chosen the treatment specified in the insurance contract.
Case No.: (2012) Huaizhong Shang Zhong Zi No. 0244
Trial court: Intermediate People's Court of Huai'an City, Jiangsu Province
Source: Bulletin of the Supreme People's Court, No. 12, 2015 (No. 230)
2. Restrict the insured's right to obtain a claim by restricting the treatment method, and the standard clause exempting the insurance company from insurance liability is invalid - the dispute between the insurance company and Wu's health insurance contract
Case Point: As commonly understood, a major illness is not associated with a specific treatment. For the insured, when suffering from a major disease, he will often combine his or her own physical condition and choose a treatment method with low trauma, low mortality and low complication rate to obtain effective treatment for the disease he has, rather than thinking of taking the treatment method limited by the insurer to ensure the payment of the major illness insurance premium. The standard clauses of an insurance company restricting the insured's right to obtain a claim and exempting themselves from insurance liability by restricting the treatment shall be deemed invalid according to the provisions of Article 19 of the Insurance Law.
Case No.: (2020) Yue 01 Min Zhong No. 2204
Trial court: Guangzhou Intermediate People's Court of Guangdong Province
Source: Guangzhou Intermediate People's Court Released Ten Typical Cases of Insurance Disputes Release Date: 2021-7-8
3. If an insurance company restricts the insured's right to obtain a claim and exempts itself from insurance liability by restricting the treatment method, the clause is invalid - Ping An Life Insurance Co., Ltd. Nanyang Center Branch of China Co., Ltd. and Du Guiqin Life Insurance Contract Dispute Case
Case Gist: The insured has the right to choose the best treatment according to his or her condition. The insurer's restriction on the treatment method of the insured's illness is not in line with the law of medical development, and it is also contrary to the purpose of signing the insurance contract. According to the provisions of Article 19 of the Insurance Law, the insurance company restricts the insured's right to obtain a claim by restricting the treatment method and exempts itself from insurance liability, which is invalid.
Case No.: (2020) Yu 13 Min Zhong No. 3968
Trial court: Intermediate People's Court of Nanyang City, Henan Province
Source: China Judgment Documents Network Release date: 2020-11-11
4. The insurer's clause limiting the scope of major diseases by treatment is invalid - Song Yanqiu v. Pacific Insurance Company refused to pay insurance premiums on the grounds that the treatment method did not meet the scope of major diseases
Case gist: Due to the constraints of various subjective and objective factors, the treatment method can be selected, so it should not become the basis and standard for the identification of major diseases, nor can it be linked to whether or not to bundle claims. In the standard clauses of the major illness insurance contract, the insurer's standard contract for the treatment of the disease does not conform to the medical law, and its limitation of the scope of the major disease by the way of treatment actually exempts the insurer from the insurance liability that should be borne according to law, restricts the insured's right to obtain a claim, and also violates the basic purpose of the insured to apply for major illness insurance, which should be judged invalid according to the provisions of Article 19 of the Insurance Law.
Case No.: (2010) Pi Shang Chu Zi No. 0107
Trial court: Pizhou Municipal People's Court of Jiangsu Province
Source: Bulletin of the Higher People's Court of Jiangsu Province, No. 2, 2011
Legal beliefs · Judicial views
Standard terms that limit the insured's treatment should be invalid
In the life insurance contract, in order to control the risk, the insurer often stipulates in the insurance contract that the insured must be treated in accordance with the medical method agreed in the contract, otherwise no compensation will be paid. For example, some medical insurance clauses will state in the contract that the surgical treatment of a major illness refers to the surgical treatment of surgical treatment that has actually been performed with open chest or open abdomen to remove, replace, and repair the lesion. For the insured to take endoscopic or interventional and other minimally invasive surgical treatment, the insurer claims no compensation on the grounds that it does not fall within the scope of insurance liability. How to understand the validity of such standard terms that limit the insured's treatment methods? Some people believe that this is an effective means for the insurer to control risks and prevent fraud, and with reference to Article 20 of the Interpretation of the Supreme People's Court on Several Issues Concerning the Application of the Insurance Law of the People's Republic of China (III), which stipulates that "if the insurer refuses to pay insurance benefits on the grounds that the insured has not received treatment at the medical service institution stipulated in the insurance contract, the people's court shall support it", which should be found to be valid.
In our view, the standard clauses restricting the insured's treatment of illness exclude the rights enjoyed by the insured in accordance with the law and should be invalid according to the provisions of Article 19 of the Insurance Law.
First, in order to prevent and correct possible unfairness in insurance contracts and prevent the abuse of standard terms, Article 19 of the Insurance Law draws on the provisions of Article 40 of the Contract Law on the invalidity of specific parts of standard terms, and clarifies that the standard terms of "exempting the insurer from the obligations that should be borne by the insurer in accordance with the law or increasing the liability of the insured and the insured, and excluding the rights enjoyed by the applicant, the insured or the beneficiary according to law" are invalid. For the insured and the insured, the purpose of signing a medical insurance contract is to obtain compensation after receiving treatment for a major disease, and the insured and the insured have the right to choose a treatment method with little trauma, low mortality and low complication rate according to their physical condition, so that the disease they suffer from can be effectively treated, which is the basic right of the patient. The insurer restricts the right of the insured and the insured to obtain insurance compensation by restricting the treatment method, which is actually to take the performance of specific obligations as a requirement for underwriting risks, which is a hidden obligation clause, which transfers the insurer's responsibility for controlling risks to the insured and the insured, aggravates the obligations of the insured and the insured, and should be invalid.
Second, the main purpose of the provision limiting designated hospitals is to prevent insurance fraud and to combat false medical behavior. In the current chaotic situation that there is indeed a huge difference in charging standards between various medical institutions, the insurer designates a designated hospital and submits the risk scope of its insurance to an institution with specialized technology to assist in review and filtering, so as to effectively control excessive medical behavior and prevent insurance fraud, which is reasonable. However, the provisions limiting the treatment are not the same. For diseases that fall under the insurance contract, choosing the best medical treatment method required to cure the body is the basic protection for the patient, and if the insurer believes that there is a possibility of excessive treatment or even insurance fraud, the insurer should bear the burden of proof. The insurer passes on the burden of proof and the risk of review to the insured through standard terms, which increases the burden of liability of the insured and is unfair.
(Excerpted from the Second Civil Trial Division of the Supreme People's Court: Guide to Commercial Trials (2018 volume), People's Court Publishing House, 2019 edition, pp. 371-372.) ）
Letter of law : Legal provisions
1. Civil Code of the People's Republic of China
Article 497:In any of the following circumstances, the standard terms shall be invalid:
(1) Having the circumstances of invalidity provided for in Section 3 of Chapter 6 of Part I of this Law and Article 506 of this Law;
(2) The party providing the standard terms unreasonably exempts or mitigates its liability, aggravates the liability of the other party, or restricts the main rights of the other party;
(c) The party providing the standard terms excludes the other party's main rights.
2. Insurance Law of the People's Republic of China (amended in 2015)
Article 19 The following clauses in an insurance contract concluded using the standard terms provided by the insurer shall be invalid:
(1) exempting the insurer from the obligations it should bear in accordance with law or increasing the liability of the applicant or the insured;
(2) excluding the rights enjoyed by the applicant, the insured or the beneficiary in accordance with law.
3. Interpretation of the Supreme People's Court on Several Issues Concerning the Application of the insurance law> of the < of the People's Republic of China (II) (Amended in 2020)
Article 9 Clauses exempting or mitigating the liability of the insurer, such as the exemption clauses, deductibles, deductible rates, proportional payments or payments, etc., in the standard contract text provided by the insurer, may be deemed to be "clauses exempting the insurer from liability" as provided for in the second paragraph of Article 17 of the Insurance Law.
The clause that the insurer enjoys the right to rescind the contract because the applicant or the insured violates its statutory or contractual obligations does not fall under the "clause exempting the insurer from liability" as stipulated in the second paragraph of Article 17 of the Insurance Law.
4. Measures for the Administration of Health Insurance
Article 22 When formulating the terms of medical insurance products, an insurance company shall respect the insured's right to receive reasonable medical services, and shall not set unreasonable or contrary to the requirements of general medical standards as conditions for the payment of insurance premiums in the clauses