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[ This case comes from the Judgment Document Network, the case number is (2020) E0103 Minchu No. 5172 ]
Basic case
- incident
[Insurance Policy Information]
On April 29, 2018, Deng Miao (pseudonym) as the insured insured " Major Disease Insurance " with the insurance company. The insured is Deng Miao himself, with a basic insured amount of 200,000 yuan, a special cancer care bonus of 40,000 yuan, and the insurance period is lifelong.
On July 30, 2019, Deng Miao was treated in the hospital due to a physical examination of "1 month ago" . He was discharged from the hospital and was diagnosed as "thyroid malignant tumor, multifocal nipples" , spending 40,000 yuan in medical expenses.
Deng Miao filed a claim application to the insurance company after being discharged from the hospital. On September 18 of the same year, the insurance company issued a "claim notice": the claim application was not approved, the insurance contract was terminated, and the premium was not refunded. The reason for was that he went to the hospital for treatment due to thyroid nodules and diabetes before taking the insurance, but did not inform him truthfully.
Deng Miao believed that when he took out the insurance, he had already gone to the designated hospital for a physical examination in accordance with the requirements of the insurance company. He signed an insurance contract with the insurance company only when the physical examination was healthy. Now the insurance company's refusal to compensate is unreasonable.
Later, Deng Miao negotiated with the insurance company many times on compensation but failed, so he filed a lawsuit with the court.
Court heard
- Defendant insurance company argued that
2. After investigation, on June 13, 2017, Deng Miao was hospitalized in the hospital for "cough, coughing, sputum for half a month, and having a fever for 3 days". The "endocrine and metabolic symptoms" in the column of the admission record were: "Yes, have a history of thyroid sarcoidosis", and Deng Miao signed and confirmed.
3. The plaintiff's behavior is an insurance policy with illness , which violates Article 16 of the " Insurance Law ". The insurance company has fulfilled its obligation to truthfully inform the insurance clauses, so the insurance company refuses to pay the insurance premium.
[Terms] The 7th item of "Health Notification" asked the plaintiff whether he is suffering from or has suffered from the following symptoms or diseases in the past, of which 7G is "positive urine sugar, diabetes, ... hyperparathyroidism or hypoparathyroidism, thyroid disease or other endocrine diseases"; for the above inquiry, the plaintiff Deng Miao's answer was "No".
- The plaintiff believes that
2. On May 17, 2018, the defendant insurance company organized the plaintiff Deng Miao to conduct a physical examination. The medical examination report issued by the hospital showed that "the hypoechoic area seen by ultrasound on the posterior wall of the uterus is considered to be a uterine fibroid, and it is recommended to have a regular follow-up examination." The other subjects were normal, and , the thyroid gland morphology was "no abnormality was seen."
Focus of dispute:
. When taking out insurance, did the defendant CITIC Prudential ask the plaintiff whether he asked the plaintiff;2. Whether the plaintiff suffered from thyroid nodules and diabetes before taking out insurance;
Court judgment
- Judgement Intention
2. Although the hospitalization record in June 2017 showed that the plaintiff had complained about thyroid nodules when he was hospitalized, there was no clear medical diagnosis to support it. The discharge records at that time and the subsequent physical examinations showed that the plaintiff's thyroid gland was normal. It is not ruled out that the plaintiff, as an ordinary person who lacked medical expertise, misjudged his condition at that time.
3. Furthermore, judging from the fact that the outpatient examination data recorded in Zhou's discharge record in 2015 was exactly consistent with the plaintiff's outpatient examination data at that time, the plaintiff's spouse Zhou did have a history of borrowing the plaintiff Deng Miao's medical insurance card for treatment. The plaintiff's opinion that the above-mentioned record of "thyroid nodules" originated from Zhou's medical information is reasonable.
Final judgment: The defendant insurance company should pay the plaintiff a major disease insurance compensation of 200,000 yuan and a special cancer care fund of 40,000 yuan, totaling 240,000 yuan.
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