bought critical illness insurance for his son
confirmed leukemia but was refused compensation
Mr. Xie told reporters that on November 14, 2018, when his youngest son Xiaozhe was less than 1 year old, his wife Ms. Gao purchased an insurance project for an insurance company for him, of which the basic insurance amount of the main insurance was 1.2 million yuan, the basic insurance amount of the additional long-term insurance was 1.2 million yuan, and the total two insurance premiums were 10,800 yuan. The contract takes effect at 19:19 on November 14, 2018.
htmlOn February 5, Xiaozhe was sent to Chengdu Women and Children's Central Hospital for examination and treatment due to repeated fever.Mr. Xie said that on February 11, the doctor recommended that the child undergo further examination and lumbar puncture and bone marrow puncture should be performed. On February 12, because the sample was not ideal, the doctor performed bone marrow apnea again, and the samples were sent to Beijing institutions for examination. On February 14, Mr. Xie obtained the examination report in the hospital, and the results showed that " bone marrow considered AML (acute myeloid leukemia)". On February 15, the test results for delivery were shown as "AML-m7? (Uncertain)". The hospital continued to conduct examinations for Xiaozhe on immunotyping, chromosomes and other items for comprehensive judgment.
htmlOn February 21, the hospital diagnosis certificate issued by the hospital showed that it was diagnosed as "acute myeloid leukemia (m7), sepsis".
Mr. Xie said that based on the various examinations on the 15th, the doctors could basically determine that Xiaozhe was suffering from leukemia. The couple remembered that they had bought Xiaozhe critical illness insurance. Leukemia was the first category of the 80 major diseases protected, "diseases related to malignant tumors", and immediately contacted the insurance company to apply for a claim.
However, on the 20th, the insurance company staff replied that Xiaozhe's situation was confirmed within the "waiting period", and he could not make a claim, but could only terminate and refund the premium.
doubts: The waiting period stipulates that "the first onset of the disease and was diagnosed by the hospital"
is based on the examination time or the examination results are issued?
Mr. Xie said that the insurance company's claim staff explained that it was based on Xiaozhe's confirmation time. On the 15th, the hospital issued relevant examination results. Xiaozhe's examination time was February 11, and February 11th happened to be the 89th day after the policy took effect, and it was still in the waiting period. Therefore, according to the insurance contract, claims cannot be settled, and only insurance refunds can be made.
htmlOn the 20th, the insurance company terminated the policy based on the insurance policy situation "a insurance accident within the 'waiting period' period agreed in the "Love Full Score Illness" contract" and returned the insurance premium to the bank card.But Mr. Xie said that he firmly does not agree with such an explanation and the insurance company's unilateral termination of the contract, because in the policy, the explanation on the waiting period is: "Within 90 days from the date when the additional insurance contract takes effect (or last re-execution), the insured's first illness and is diagnosed with a "critical disease" or "specific minor and serious illness" stipulated in this additional insurance contract. We (insurance company) do not assume insurance liability and will refund you The insurance premium paid for this surcharge contract will be terminated. The main insurance contract will be terminated at the same time, and the insurance premium you paid will be refunded. This 90-day time becomes the waiting period. "
Regarding "the first onset of the disease and confirmed by the hospital", Mr. Xie believes that the time for the diagnosis should be the time when the report is issued, rather than the time when the sample is taken for examination. According to Xiaozhe's examination report, this time is February 15, which has exceeded the 90-day "waiting period".
htmlOn 21, after receiving the insurance company's paper "claim decision notice", Mr. Xie and his wife went to the insurance company to file a complaint.Insurance company responded to
Special cases are being reviewed and evaluated
22. On the 22nd, the insurance company replied that "the first onset of the disease and was diagnosed by the hospital" is a fixed clause in the insurance contract, and the company will strictly implement it in accordance with the contract.
The customer was hospitalized three times within 90 days of the contract taking effect, with multiple diagnoses, and the specific descriptions are different, which are special cases and disputes arise.
htmlOn March 21, the insured provided two new hospital certificates of illness and expressed objections to the claim. The company has accepted the case and is currently being reviewed and evaluated according to the new materials, and will be properly handled in accordance with the contract.Regarding the three hospitalization records within 90 days of the contract's effectiveness, Mr. Xie said that on November 18, 2018, that is, 4 days after taking out insurance, Xiaozhe had eczema, his family took him to the hospital for a series of examinations and treatments, and was diagnosed with immune thrombocytopenia. He had hospitalization records, but the disease was not covered by the critical illness insurance coverage.
(Source: Red Star News Client)
