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Keywords of this article:
Accidental injury Litigation cases Claims
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Case introduction
Insured Ms. Li insured in a certain insurance company, she insured with a 500,000 yuan insurance amount accidental injury insurance a copy.
On the morning of September 10, 2020, Ms. Li was found dead at the corner platform of the stairs at home by her family.
After receiving the report, the public security organs will eliminate criminal liability after on-site inspection and medical institution inspection.
claims
Ms. Li’s family applied for a claim from the insurance company (hereinafter referred to as “Guarantee”) on September 15 (after cremation), and provided the “Medical Certificate of Resident Death (Inferred) Book” (hereinafter referred to as “ Death Certificate ”), and the cause of death was registered as an “accident”.
After receiving the report, the insurance department’s claim staff immediately informed the family that the autopsy needed to perform an autopsy in order to verify Ms. Li’s real cause of death (because it has been cremated, the autopsy is obviously impossible).
After investigation and verification: Ms. Li
9/10
found dead by family
9/11
household registration cancellation
9/12
household registration cancellation
9/12
cremation
Another investigation found that Ms. Li had a long-term habit of taking hypertensive drugs. She diagnosed hypertension in the outpatient clinic with a level 3 hypertension. She was diagnosed with coronary heart disease many years ago, and had violated health notifications (the insurance policy had a health notification questionnaire when insured);
The cause of death recorded in the "Death Certificate" was based on the family's self-report and there was no medical or test basis. Ms. Li did not have any symptoms of accidental injury when she was found dead. When she canceled her household registration, the police station asked the family to perform an autopsy on the insured to verify the real cause of death, but the family refused to cooperate. After multiple investigations, it was still impossible to find out Ms. Li's real cause of death, and the insurance department refused to fulfill its insurance liability.
Ms. Li’s family filed a lawsuit with the people’s court.
Plaintiff's statement summary
has fulfilled its obligation to provide evidence, and the evidence has clarified the nature and cause of the insurance accident.
01
Article 22 of the Insurance Law stipulates that "the beneficiary shall provide the insurer with the certificate and information related to confirming the nature, cause, degree of loss of the insurance accident that they can provide." At the same time, the policy clause stipulates that the application for payment of death insurance must submit "the insured death certificate or autopsy report issued by the public security department or a medical institution recognized by both parties".
When applying for the claim, he submitted the "Death Certificate" and other materials stamped and issued by XX County Hospital and XX Police Station, and has completed the obligation to provide evidence.
02
The evidence validity of the "Death Certificate" should be recognized.
"Death Certificate" is obtained by the beneficiary in accordance with the rules that the general public can understand and comply with, and is applied for by legal institutions and procedures. It does not violate the legal provisions and contractual agreements; the certificate comes from the joint platform of the local public security, civil affairs, medical institutions, etc., and has credibility.
"Interpretation of the Supreme People's Court on the Application of the Civil Procedure Law of the People's Republic of China" Article 114 stipulates that "what records in documents produced by state organs or other organizations with social management functions in accordance with the law are presumed to be true, except where there is evidence to the contrary to the contrary to overturn it."
" Several Provisions of the Supreme People's Court on Evidence in Civil Litigation " also stipulates that the proof of the official document certificates produced by state organs and social groups in accordance with their powers is generally greater than other documentary evidence.
03
medical record of the insured's diagnosis of coronary heart disease before taking out insurance, and a history of hypertension , but it cannot be determined based on this that his death was caused by "disease, non-external cause".
After treatment, the insured's physical examination report showed that the coronary heart disease had been cured and his blood pressure was normal.
The above evidence and facts objectively have also ruled out or reduced the probability of death by "coronary heart disease and hypertension".
Therefore, it is determined that "accident" does not violate evidence and facts, and it complies with the principle of proximity in the insurance law .
04
"Interpretation of the Supreme People's Court on Several Issues Concerning the Application of the
In accordance with the proximal cause principles and judicial practice of the Insurance Law, the provisions of the aforementioned judicial interpretation should be applied to reflect the principles of legality and fairness.
Defendant defense summary
1.
A peer investigation was conducted before trial and explained the situation of the peer share to the judge that Ms. Li's insurance amount was relatively high. The first instance court accepted two litigation cases in the case at the same time. Company A's target was 500,000 yuan and Company B's target was 1.2 million yuan. The reason for Company B's rejection of compensation was also unknown. In addition, Company C has a policy, which also refused to pay compensation based on the unknown cause of death, which attracted the attention of the judge.
2.
After the customer was cremated, there was a human intentional delay in reporting the case to evade the autopsy process of the Insurance Department, which does not meet the general handling process of claims cases.
3.
The security department conducted an investigation and visited the police station and issued a death diagnosis doctor, but the relevant institutions and personnel did not agree with the security department. In order to find out the facts of the case, the judge asked to issue an investigation letter or send someone to investigate to clarify the truth of the case.
4.
After the insured was cremated, the family issued a death certificate in the hospital in the non-accidental place, and the effectiveness of the evidence was not recognized.
Litigation Results
1 and second instance defendants won the lawsuit
Referees mainly based on
1,
1,
1,
The court questioned the doctor in charge of the "Death Certificate" involved in the case and made an inquiry record. The doctor stated that the "cause of death" was registered as "accident", and it was filled in according to the statements of the family of the deceased, without objective basis.
2.
In addition, the police station police officers and forensic doctors arrived at the home of the deceased, and the two parties also involved insurance and autopsy during the communication. However, because the family members did not cooperate, the body of the insured was not performed to clarify the cause of death.
3,
The beneficiary is the party who provides the burden of proof of the insurance accident, nature and cause.
The beneficiary provided a "Death Certificate" to prove that the cause of death of the insured was an "accident". However, based on the statement of the doctor and the content of the police video of the police, the above-mentioned records of the cause of death were formed based on the statements of the deceased's family and were not the conclusion opinions of the relevant issuing unit. Therefore, this evidence alone is not enough to prove the facts to be proved by the plaintiff's claim, and he should bear the adverse legal consequences of the inability to provide evidence.
4.
beneficiary believes that the "Death Certificate" submitted by him was jointly issued by medical institutions and public security organs, which is sufficient to prove that the cause of death of the insured was accidental injury accident .
The court believes that the basis for this claim is insufficient, and the reasons are as follows: First, according to the provisions of the "Notice of the National Health and Family Planning Commission , the Ministry of Public Security and the Ministry of Civil Affairs on Further Standardizing the Management of Medical Certificates and Information of Population Death" (Guowei Planning Fa [2013] No. 57), the medical certificate of population death is a medical certificate issued by a medical and health institution that explains the death of residents and their causes.
Since January 1, 2014, medical and health institutions in various places have used the new version of the "Death Certificate" formulated nationwide.
"Death Certificate" is a certificate for population management such as household registration cancellation, funeral and other population management, and is jointly managed by the health and family planning, public security and civil affairs departments.
"Death Certificate" The issuing unit is a medical and health institution responsible for treatment or normal death investigation; an abnormal death certificate without treatment shall be processed by the public security and judicial department in accordance with current regulations and procedures.
In this case, the death of the insured is an abnormal death and has not been treated by the hospital. The untreated abnormal death certificate should be processed by the public security and judicial department in accordance with the current regulations and procedures, rather than a medical institution.
However, after arriving at the scene, the forensic doctor of the public security organ failed to conduct an autopsy on the insured to determine the cause of his death due to the uncooperation of the insured's family, which resulted in the failure to find out the cause of death of the insured, so the insured should have the cause of death unknown.
5.
According to Article 60 of the "Implementation Rules for the Management Regulations of Medical Institutions" of the National Health and Family Planning Commission, the "Death Certificate" issued by a medical institution for those with unknown causes of death is only a diagnosis of whether to die, and no diagnosis of the cause of death.
If the relevant parties require a diagnosis of the cause of death, the medical institution must appoint a doctor to perform an autopsy and the relevant cause of death examination before the cause of death can be diagnosed.
Judging from the investigation of the first instance court, the medical institution that issued the "Death Certificate" clearly stated that it filled in the "Accident" column in the "Cause of Death" on the certificate, which was recorded based on the statements of the deceased's family. It did not assign a doctor to perform an autopsy and test the cause of death. Therefore, the "Death Certificate" issued by the medical institution can only prove the fact that the insured died, and cannot diagnose the cause of death.
Police Station stamped the "Death Certificate" and stated that "the household registration has been cancelled", which is in accordance with the provisions of the "Notice of the National Health and Family Planning Commission, the Ministry of Public Security, and the Ministry of Civil Affairs on Further Standardizing the Management of Medical Certificates and Information of Population Death", and performs its responsibilities for canceling household registration and signing.
In summary, the "Death Certificate" can only prove the fact that the insured died and the household registration has been cancelled, and it cannot be determined based on this that the public security organs and medical institutions have confirmed the cause of the insured's death as an accidental injury accident.
6.
Article 21 of the Insurance Law of the People's Republic of China stipulates: "After the insured, the insured or the beneficiary knows that the insurance accident occurs, he shall promptly notify the insurer. If the nature, cause, degree of loss of the insurance accident is difficult to determine if the insurer is intentionally or due to gross negligence, the insurer shall not bear the liability for compensation or payment of the insurance money for the undetermined part, except that the insurer has known or should promptly know that the insurance accident occurred through other channels."
It can be seen from this that promptly notifying the insurer is the legal obligation of the insured, the insured or the beneficiary.
After the insured dies, the insured or beneficiary shall promptly notify the insurer so that the insurer can promptly investigate and determine the cause of the insured's death.
If the beneficiary fails to notify the insured in time, the insured will be cremated, or although it has not been cremated, he is unwilling to perform an autopsy. After clearly explaining the legal consequences to him, he still insists on the cause of the death of the insured, and other circumstances are difficult to determine, the insurer shall not bear the liability for the undetermined part, except that the insurer has known in time or should know in time that the insurance accident occurred through other channels.
In this case, there is no evidence that the insurance company has known in time or should have known in time that the insurance accident occurred (i.e., it is not possible to know before the insured is cremated).
The insurance beneficiary involved in the case violates the legal obligations and cremates the insured without promptly notifying the insured, which makes the cause of the insured's death difficult to determine. The insurer shall not bear the liability for the undetermined part according to law.
Case summary
"
Insurer
1,
1 for the cause of the accident is unclear, or only the family members unilaterally claim it as "accident" In cases, after receiving the report, promptly notify the autopsy, inform the relevant legal consequences, go to the site for investigation in a timely manner, and understand the detailed process of the accident.
2.
know the issuance process and basis for the "Death Certificate", whether it complies with relevant regulations, and whether there is any violation of general logic.
.
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4.
0. During litigation, you can clarify the requirements, basis and effectiveness of the issuance of death certificates, including citing the "Notice of the National Health and Family Planning Commission, the Ministry of Public Security, and the Ministry of Civil Affairs on Further Standardizing the Management of Medical Certificates and Information of Population Death" (Guowei Planning Fa [2013] No. 57) "Implementation Rules of the Regulations on Medical Institutions Management 》Relevant provisions.
5.
involves the part that clearly states the obligation to provide evidence, and try to provide traceability procedures for insurance, as well as implementation requirements and other related documents.
"
"
Insured person
1,
timely report the case.
After the accident occurs, the obligation to notify the insurer will be fulfilled in a timely manner so that the insurer can promptly investigate and confirm the nature, cause and degree of loss of the insurance accident.
2,
Seek truth from facts.
provides claims materials as required, avoid being clever when obtaining relevant materials, resulting in subsequent adverse consequences. Sometimes cleverness is mistaken for cleverness.
3.
If health notification is involved when taking out insurance, be sure to inform the truthfully to avoid unnecessary disputes.
The content of the laws and regulations involved in the article has been simplified. It is recommended to query and confirm the original version by yourself.
Also declare again: The views in the article do not represent any party, they are only personal understanding, and if you have different opinions, you can also communicate.
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