Please click to follow before reading, and ask questions such as insurance consultation, claim rights protection, etc. Please send private messages to claim help and answer questions. Case number: [(2021) Hebei 0606 Minchu No. 10264] Case type: [Critical Illness Insurance Claim C

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Case No.: [ (2021) Hebei 0606 Minchu No. 10264 ]

Case Type: [ Critical Illness Insurance Claim Case] ​​

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Case Details

In July 2018, the plaintiff's father Li insured a major disease insurance for Xiao Li (pseudonym) in an insurance company with an insurance amount of 400,000 yuan and the insurance period is lifelong.

insurance terms stipulate that: item 86 of the 100 major diseases is infant progressive spinal muscular atrophy , which stipulates that the insured person will bear the insurance liability for this disease within two years after birth.

In July 2021 and August 2021, the plaintiff Xiao Li was diagnosed with spinal muscular atrophy and progressive spinal muscular atrophy by the Provincial Children's Hospital and the Municipal Children's Hospital respectively. Afterwards, the plaintiff Xiao Li applied for a claim from the insurance company. The insurance company refused to pay the insurance on the grounds that the plaintiff was over 2 years old when he was diagnosed in the hospital and did not fall within the scope of the coverage of progressive spinal muscular atrophy in infants with major diseases stipulated in the insurance contract.

The court heard

The insurance company believed that during the conclusion of the

insurance contract, the insurance company explained to the policyholder Li the insurance liability, liability exemption , the scope of protection, insurance terms, etc., and has fulfilled the obligations such as prompts and instructions in accordance with the law. The defendant insurance company did not have any fault. The conclusion of the insurance contract was the true intention of both parties. After the insurance contract was established, the plaintiff Xiao Li unfortunately fell ill for treatment, and Li later applied for compensation from the defendant. After verifying that Li submitted relevant treatment cases, combined with the relevant provisions of the insurance contract terms, the plaintiff's application for this time did not meet the major disease conditions stipulated in the contract. Therefore, the defendant's insurance company does not bear the liability for major disease insurance.

Court judgment

Controversy focus: Does the disease the plaintiff suffers from meet the compensation standards of the insurance contract?

. Progressive spinal muscular atrophy is determined as the insurance coverage according to item 86 of in personal insurance contract. The evidence provided by the plaintiff Xiao Li fully proves that the disease he suffers from is progressive spinal muscular atrophy and is covered by the contract for major diseases. The plaintiff's evidence complies with the provisions of Civil Procedure Law and Article 22 of the Insurance Law. The preliminary burden of proof has been completed, that is, the insurer has provided "the proof and information that he can provide related to confirming the nature, cause, degree of loss of the insurance accident, etc." stipulated in Article 22 of the Insurance Law. The defendant believes that the plaintiff Xiao Li’s application has not met the criteria for major disease conditions stipulated in the contract and has no factual basis.

. Plaintiff Xiao Li presented evidence to prove that the disease progressive spinal muscular atrophy is covered by the insurance contract for major diseases. The defendant insurance company must prove that the plaintiff Xiao Li’s claim has disclaimer before it can refuse compensation based on this. However, the defendant's evidence on the reasons for the exemption of insurance payment during the trial of this court cannot exempt him from compensation. The defendant's evidence cannot confirm that the defendant has fulfilled the obligation to clearly state the liability exemption clause; the defendant did not make a clear explanation of "it is not insurance liability if it is over two years of age when the diagnosis is confirmed."

. According to the interpretation of progressive spinal atrophy in infants and Article 498 of the " Civil Code " "If there is a dispute over the understanding of the format clause, it shall be interpreted in accordance with the usual understanding. If there are more than two interpretations of the format clause, an explanation shall be made that is not conducive to the party providing the format clause. If the format clause and the non-format clause are inconsistent, non-format clauses shall be adopted." Therefore, this court does not accept the defendant's claim that "the plaintiff Xiao Li was over two years old when he was diagnosed and does not belong to insurance liability."

In the end, the court ruled that the defendant insurance company should bear the insurance liability as stipulated in the insurance contract and pay the plaintiff Xiao Li 400,000 yuan in insurance.

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