has written several insurance dispute cases before about "the content of the failure to truthfully inform health has no causal relationship with the accident applying for claims, so the insurance company cannot refuse compensation." The corresponding legal provisions are shown in the figure below.
However, some friends may confuse the refusal of compensation and the termination of insurance contracts.
In fact, although in this case, the insurance company of cannot refuse compensation, it does not mean that the insurance contract cannot be terminated. After termination of the insurance contract, the insurance company only needs to pay the insurance premium before termination of the contract, and no compensation is required for insurance accidents that occur after termination of the contract.
For details, please take a look at the following verdict in the insurance dispute. Although the case is simple, the content contained is quite comprehensive.
(case number: (2021) Beijing 74 Minzhong No. 854)
Let’s briefly talk about the process of the matter first.
As the insured, Qin took out the long-term medical insurance for Good Medical Insurance. The first period will be insured from January 8, 2019, and the guaranteed renewal period will be 6 years. Qin renewed his insurance policy on January 8, 2020.
In May 2020, Qin was hospitalized for treatment after being ill and was discharged from the hospital and was diagnosed as: 1. Uterine leiomyoma; 2. Left vitreal hemorrhage; 3. Bicataract; 4 Bidiabetic retinopathy; 5. Grade 3 hypertension; Type 6, Type 2 diabetes; 7. Fungal vaginitis. The total hospitalization amount is 23,053.24 yuan. The above-mentioned medical insurance payment is 9331.45 yuan, and the individual payment is 13721.79 yuan.
In addition, Qin visited the ophthalmology clinic on May 8, and his total expenditure was 380.2 yuan.
Qin applied for the first time on June 9, and the insurance company paid the compensation as agreed. After
, Qin applied for the second claim on June 12, but the insurance company learned from his claim information that Qin did not fulfill his obligation to truthfully inform the fact that he had diabetes when he was insured. If the normal notification of diabetes will cause the insurance to be rejected, it is sufficient to affect the insurance company's decision whether to agree to underwriting or increase the insurance premium rate.
Subsequently, the insurance company issued a notice of termination of the contract and a notice of refusal on July 3, 2020 (from the time of knowing the reason for termination, it did not exceed the statutory 30-day deadline).
also found out that Qin has undergone corresponding treatments since October 2020.
The focus of this insurance dispute is: whether the insurance company has the right to terminate the insurance contract and whether it should compensate for the medical expenses after the insurance contract is terminated.
sorted out the content of the court's trial judgment. The insurance dispute can be divided into two aspects.
On the one hand, Qin's insurance claim application has no causal relationship with diabetes that he did not truthfully inform, and the insurance company has no evidence to prove that there is a causal relationship between the two, so the insurance company should pay the insurance premium for the medical expenses incurred before termination of the insurance contract. The insurance company has also fulfilled its compensation obligations.
On the other hand, Qin did not fulfill his obligation of truthful notification due to gross negligence, and the matter was sufficient to affect the underwriting conclusion of the insurance contract. After the insurance company learned about the situation, it complies with the law to terminate the contract within 30 days stipulated by the law. The insurance company does not need to pay compensation for insurance accidents that occur after the termination of the insurance contract.
The above-mentioned insurance claims dispute is indeed classic, and all the key issues of failing to fulfill the obligation to truthfully inform. Everyone can take the lead. The rights and interests that should be protected must be maintained, and the obligations that should be expressed must also be fulfilled.
