On April 1, 2018, Zhou Yi (pseudonym)'s wife used Zhou Yi as the insured to insure a certain insurance company's major disease insurance . In November 2019, Zhou Yi went to the hospital for examination due to discomfort in throat and was diagnosed with " papillary thyroid cancer ". Later, Zhou Yi applied for a claim to the insurance company but was rejected. After negotiations with the insurance company but failed, Zhou Yi found "Asses Help" for consultation, and finally the claim help lawyer helped him successfully get a compensation of 300,000 yuan in critical illness insurance.
Basic information of cases
Insurance insurance: Serious illness insurance
Insurance cause: Papillary thyroid cancer
Reason for refusal: The first time a contract occurred after non-waiting period, the disease stipulated in the contract
Dispute amount: .3 million
Insurance: On April 1, 2018, Zhou Yi's wife insured him with the insurance company's major disease insurance, the insurance amount was 300,000 yuan, waiting period of 90 days.
is in danger: On November 29, 2019, Zhou Yi went to the hospital for treatment due to discomfort in his throat and was diagnosed with "papillary thyroid cancer".
Claim: Insurance company refused to pay the compensation on the grounds that Zhou Yi's disease was not "after the waiting period" and "first occurrence" and did not meet the compensation conditions.
Focus of dispute
How effective is the "waiting period" clause, "critical disease insurance premium" clause and "first occurrence" clause in the insurance contract involved? Whether the insurer can invoke this clause to refuse compensation.
Defendant insurance company argued that
according to the relevant provisions of the insurance contract involved, it only pays insurance for major diseases that are subject to the "first occurrence" of the insurance contract. Although Zhou Yi was diagnosed with thyroid cancer after the waiting period, it does not constitute the first occurrence after the waiting period. Because Zhou Yi had symptoms such as thyroid nodules and goiter before the waiting period. Therefore, Zhou Yi's situation does not constitute the "after the waiting period" and "first occurrence", so he should not bear the liability for insurance payment.
Basic judgment summary
Regarding the validity of the "waiting period" clause, "critical disease insurance premium" clause and "first occurrence" clause in the insurance contract involved.
In this case, the plaintiff and the defendant had no objection to the diagnosis time of thyroid cancer after the waiting period. However, the defendant insurance company claimed that according to Article 9.9 of the insurance contract, the initial occurrence of refers to the first occurrence of the insured person or the abnormal physical condition of the first occurrence of a major or mild disease, including all the symptoms and signs related to a major or mild disease. The plaintiff was diagnosed with a thyroid nodule on August 7, 2017. The thyroid nodule is a precursor and related symptoms of thyroid cancer. Therefore, the plaintiff's "first occurrence" time was August 7, 2018. Obviously, before the waiting period expired, the defendant's refusal to compensate had facts and legal basis.
The plaintiff argues that the time of the first occurrence should be based on the time of the diagnosis of a major disease.
The court held that Article 9.9 "first occurrence" clause is an interpretation clause and is an explanation of the "first occurrence" in the "critical disease insurance premium" clause in Article 2.4 "insurance liability". It cannot be applied separately, but should be understood in combination with the "critical disease insurance premium" clause in Article 2.4 "insurance liability" clause and "waiting period" clause. Article 2.4 "Critical Illness Insurance Payment" clause, "Waiting Period" clause and Article 9.9 "First Accident" clause jointly stipulate the scope of insurance liability of the insured in the case of a serious illness in the case of a serious illness by the insured. Therefore, the "Waiting Period" clause, "Critical Illness Insurance Payment" clause and "First Accident" clause are of course binding on the plaintiff.
Regarding whether the defendant can invoke the "first occurrence" interpretation clause.
According to the relevant provisions of the insurance terms involved, the defendant only bears insurance liability for insurance accidents that occur after the waiting period.The plaintiff's claim that the defendant's definition of the first occurrence does not conform to ordinary people's understanding and prediction of the first occurrence. The first occurrence should be understood as the first confirmed diagnosis of a serious illness, rather than the relevant symptoms and signs. The interpretation of "first occurrence" in the contract involved is a person intentional expansion of the scope of "insurance with illness" and seriously infringes on the rights and interests of the insured.
This court believes that "first occurrence" is reflected in two places in the terms of the contract involved: one is the "critical disease insurance premium" clause, and the other is the "first occurrence" clause. The terms of the "Critical Illness Insurance" stipulate: "When the insured first occurs and is diagnosed with a major disease as stipulated in this contract by a specialist in the hospital, the defendant shall pay the major disease insurance as agreed."
According to the general understanding, the "first occurrence" in this clause should refer to the first major disease occurrence, and this clause also makes clear agreements on the time node for the first major disease occurrence, that is, the time of diagnosis shall prevail. However, in the interpretation of Article 9.9, the defendant interpreted "first occurrence" as "a precursor or abnormal physical condition for the first time when a major or mild disease occurs", and the meanings of the two are obviously inconsistent.
According to Article 41 of the " Contract Law ": If a dispute arises about the understanding of the standard terms, it shall be explained in accordance with the usual understanding. If there are more than two interpretations of standard terms, an explanation should be made that is not conducive to the party providing standard terms. In this case, the "Critical Illness Insurance" clause is a standard clause. The "first occurrence" in the standard clause "Critical Illness Insurance" should be explained that it is unfavorable to the defendant, that is, it is understood as the first diagnosis of a major disease. Therefore, this court will not accept the defendant's defense opinion, and the defendant shall pay the plaintiff's major illness insurance as agreed.
In summary, the court ruled that the defendant insurance company paid Zhou Yi 300,000 yuan in major disease insurance premiums in accordance with the insurance contract.
(After the first instance judgment, the defendant did not appeal, and the execution has been completed)
Little Helper's opinion
The focus of this case is on the determination of the effectiveness of the waiting period clause in the insurance contract. The waiting period, also known as the observation period or the exemption period, means that even if an insurance accident occurs during the designated period when the insurance contract takes effect, the beneficiary cannot obtain insurance compensation. The purpose of setting up a waiting period for insurance contracts is to prevent the insured from immediately obtaining insurance benefits even though they know that an insurance accident will occur.
In judicial practice, the court determines whether the waiting period clause in the insurance contract is valid, and should distinguish whether the waiting period clause belongs to a general format clause or an disclaimer clause based on the content and arrangement of the insurance clause. According to the law, if an insurance contract is concluded using the standard terms provided by the insurer, the insurer shall attach the standard terms to the insured. The insurer shall explain the content of the contract to the insured and shall follow the principle of fairness to determine the rights and obligations between the two parties. If the insurer uses the standard terms to exclude the important rights of the insured or the insured or exempt his main obligations, the clause shall be deemed invalid. The disclaimer is a clause formulated by the insurer to mitigate or exempt his liability. The effectiveness of the disclaimer depends on whether the insurer has fulfilled his special reminder and explanation obligations in accordance with the law.
In this case, thyroid nodules are common clinical symptoms, and the symptoms are not obvious. Most of them are benign nodules. Although malignant lesions are not common, their properties are difficult to identify. They are not the only thyroid cancer symptoms. The characteristics of this disease cause people to not be discovered in time in daily life, and often require in-depth examinations to diagnose it. Although Zhou Yi was diagnosed with thyroid nodules before taking out insurance, it cannot be determined based on this that the thyroid nodules will definitely evolve into thyroid cancer. As an ordinary person who does not have professional medical knowledge, the insured cannot determine which symptoms belong to the insurance company's exemption reason . Unless the insurance contract matches the insurance contract to attach various "symptoms or signs" clauses, the insurance contract clauses in this case do not stipulate "thyroid nodules" as symptoms or signs of thyroid cancer.There are two different interpretations of the insurance contract involved in the case for "first occurrence". Based on the principle of unfavorable interpretation of , if there are more than two explanations for the first occurrence in the contract, the people's court shall make an explanation that is beneficial to the insured.
Little helper suggests that all policyholders must understand the content of the insurance contract in detail when insuring insurance, and especially pay attention to the waiting period clauses in the insurance contract. Some diseases take a long time from abnormality detection, examination to diagnosis. The insured should pay attention to distinguishing the different diseases stipulated in the waiting period clause, such as the fact that mild symptoms are diagnosed, severe diseases are diagnosed or related diseases are given during the waiting period, and sign the insurance contract with full knowledge. Insurance companies should improve the corresponding notification procedures. If the waiting period clause is involved in the format contract, evidence is required to prove that the insured is in the waiting period agreed upon by the waiting period, and provide a reasonable basis for his refusal to compensate.
*The case in this article is a real case of claim help users. In order to protect the privacy of the parties, the names in the article are all pseudonyms.
This article is reproduced from the "Account Bug" official account or official website. TheAccount Bug gathers more than 1,000 lawyers and insurance claims rights protection experts. Here you can get free insurance claims rights protection consultation.
Previous recommendations
————
● Insurance company bargained "either accept 200,000 or sue me" Court: compensation of 360,000...
