The customer accidentally fell and died. After the report was made, the insurance company sent people to the scene to investigate the situation on the same day. After the investigation, relatives were asked to prepare claim materials for applying for claims. Afterwards, relatives

A customer accidentally fell and died. After the report was made, the insurance company sent people to the scene to investigate the situation on the same day. After the investigation, relatives were asked to prepare claim materials for applying for claims.

Afterwards, the relatives buried the deceased and waited for the insurance company's claim settlement result.

However, what was waiting for him was that "the deceased had no external injuries or bleeding after the fall, and it was not considered an 'accidental injury' death, so the claim was refused."

At the same time, the autopsy was not mentioned when the personnel were dispatched to investigate that day. However, after the relatives buried the deceased, the insurance company cited "without an autopsy, the true cause of death cannot be determined" as one of the reasons for refusing to pay out the insurance money.

A few days ago, a judgment was published on the Judgment Documents Network, making this dramatic insurance claims dispute public.

accidentally fell and died. Should the insurance company pay the accident insurance money? Let’s see how the court decides.

Rejection of accident insurance premium due to accidental fall and death?

The story of the incident starts from last year.

In December 2021, Mr. and Mrs. Tian and their daughter, a family of three, purchased a "China Life Family Planning Family Group Accident Insurance" from the Luonan Branch of China Life Insurance Company (hereinafter referred to as: China Life Luonan Company). The amount is 30,000 yuan, 10,000 yuan per person for a family of three, and the insurance period is one year.

On December 23 of the same year, something unfortunate happened. Tian accidentally fell down while going down the steps at home and landed on his head.

After the incident, Tian’s relatives immediately sent him to the local village clinic for rescue, and then to the local town health center for rescue.

However, Tian eventually died after resuscitation failed.

Since the family members all purchased group accident insurance from China Life Luonan Company, relatives reported the accident to China Life Luonan Company on the day of the accident, and the company immediately sent people to the scene to investigate the circumstances of Tian’s death.

Then, China Life Luonan Company asked Tian’s relatives to prepare all the application materials required for claim settlement, and filled out the claim application form provided by China Life Luonan Company.

On December 26 of the same year, relatives buried the deceased Tian in their own village with the help of relatives and friends in the same village.

After taking care of Tian’s funeral and submitting all claim information as required by the insurance company, Tian’s relatives are waiting for the insurance company’s claim results.

However, what awaited was the news that China Life Luonan Company "refused to pay compensation".

Tian's relatives could not accept this and had no choice but to take China Life Luonan Company to court, requesting the court to order China Life Luonan Company to pay 10,000 yuan in insurance benefits as stipulated in the insurance contract.

Filed "no autopsy" after the deceased was buried

According to the appeal of Tian's relatives, on the day of the accident, the relatives informed the salesman of China Life Luonan Company about the accidental death of Tian. The salesman also investigated the circumstances of Tian's death on the same day. An investigation was conducted and it was determined that the death was accidental, and within the insurance period, it was a compensable situation. So let the relatives prepare and submit all the materials required for the claim.

However, China Life Luonan Company did not agree with the appeal of Tian’s relatives and put forward two arguments as to why it refused to compensate.

China Life Luonan Company stated that it did not determine that Tian’s death was accidental, and “accidental death” and “accidental injury death” are not the same concept; furthermore, the fact of Tian’s death did not fall into the “accidental injury” stipulated in the insurance contract. , Tian fell down the steps and died, which was not an insured accident.

In this regard, China Life Luonan Company also specifically explained the relevant clauses in the insurance contract.

China Life Luonan Company said that according to the relevant provisions in the insurance contract, accidental injury refers to the physical injury directly caused by external, sudden, unintentional, non-disease objective events. In this case, Tian’s body was not injured when he died, and there was “no trauma or bleeding.”

China Life Luonan Company also argued that the relatives did not provide evidence to prove the "craniocerebral injury" mentioned in the complaint. The deceased was not rescued, was not sent to the hospital, and no autopsy was performed to determine the true cause of death.

Therefore, China Life Luonan Company claimed to the court that the appeal of Tian’s relatives could not be established and requested the court to reject the appeal of Tian’s relatives.

The court ordered the insurance company to compensate the insurance company 10,000 yuan in insurance money

Regarding the respective claims and demands of the two parties, the court held that the "China Life Family Group Accident Insurance" contract involved in the case was legal and valid and protected by law.

However, the court did not agree with the argument put forward by China Life Luonan Company that "Tian had no trauma or bleeding after the fall, and his body was not harmed. The death was not considered an 'accidental injury' and should not be compensated."

Regarding China Life Luonan Company’s two arguments for refusing compensation, the court raised three points to refute it.

First of all, it was not that Tian was not rescued after he fell.

According to the facts ascertained by the court, after Tian fell at home, he was rescued by the local village clinic and town health center. He was declared dead after the rescue was ineffective.

According to the medical death certificate jointly issued by the two medical institutions, Tian died of craniocerebral injury due to a fall.

The court pointed out that this diagnostic conclusion was made by the doctor based on the fact that Tian’s head landed on the ground after falling, as well as the symptoms and medical experience before death, and it complied with medical standards.

Secondly, after Tian’s relatives reported the case, China Life Luonan Company sent people to the scene to conduct an investigation and asked the relatives to fill in and submit all required claim materials. Thereafter, relatives bury the deceased.

The court emphasized that this showed that the relatives had completed preliminary evidence as required by China Life Luonan Company.

However, after Tian was buried, China Life Luonan Company actually made a request that "Tian had no external injuries, no bleeding, and no autopsy was performed."

In this regard, the court stated that China Life Luonan Company did not inform the relatives of the deceased in advance that an autopsy should be performed, or the consequences of not performing an autopsy. Therefore, China Life Luonan Company should bear the adverse consequences itself.

In addition, the court further pointed out that according to the relevant provisions of the Insurance Law, if the insurance contract entered into by the insurer has a dispute over the terms, the terms shall be interpreted in accordance with common understanding.

Therefore, the court held that Tian’s fall and death was an “accident” as commonly understood. This fact was consistent with the “accidental injury” proposed by China Life Luonan Company (referring to external, sudden, unintentional, and non-disease injuries). .....causing bodily harm) does not conflict with the meanings.

Therefore, the court ruled that Tian’s death was an accidental injury, and China Life Luonan Company paid an insurance premium of 10,000 yuan to Tian’s relatives.

At the same time, China Life Luonan Company will bear the halved case acceptance fee.