After the insured died unexpectedly
Family members do not agree to conduct autopsy tests and identification
Insured company fails to identify
cannot find out the reason for the death and refuse to compensate
Will the court support it?
Basic facts
The insured Zhang took out accidental injury medical insurance at the defendant insurance company . On February 28, 2022, Zhang was taking a shower in the bathroom at home, and accidentally slipped and injured his head and died on the spot. issued a "Medical Certificate of Resident Death (Inferred)" on the local health center where Zhang was rescued. 's cause of death was recorded as brain trauma.
On March 1, 2022, the insurance company issued an accident inspection notice, suggesting that Zhang's autopsy and autopsy test be tested. Zhang's family signed the notice and clearly expressed their disagreement. The next day, Zhang's body was cremated. insurance company refused to pay compensation for failing to identify the cause of death of the insured person and unable to prove that the accident is within the scope of insurance.
The two parties failed to negotiate many times, and Zhang's family filed a lawsuit with the Yuanjiang Municipal People's Court, and asked the defendant insurance company to pay 150,000 yuan in insurance.
Court judgment
After trial, the court held that the focus of The issue of the allocation of burden of proof for Zhang's cause of death .
In this case, after Zhang died, his relatives promptly reported the case to the insurance company and provided a medical certificate of resident death (inference) for the death of resident. The plaintiff has provided the evidence and information that he objectively can provide related to confirming the nature and cause of the insurance accident involved in the case, and it can be determined that he has fulfilled his obligation of proof for Zhang's accidental death.
When the plaintiff completes the burden of proof and the defendant cannot provide evidence to refute, combining the statements of Zhang Wei's family and the records of the medical certificate of death (inference) book, it can be determined that Zhang Wei fell to the ground and suffered head injury before his death, which falls within the scope of responsibility for accidental injury insurance , so the defendant insurance company assumes insurance liability as agreed.
Although Zhang's family signed an accident inspection notice after the accident, clearly expressing their disagreement of autopsy. However, autopsy examination and identification are not necessary procedures for compensation for accidental death insurance as agreed in the insurance contract between the two parties, and the accident inspection notice involves a major matter of exempting from liability. When the plaintiff signed the notice, the defendant insurance company failed to fulfill its clear and sufficient explanation obligation, so the defendant insurance company did not pay compensation based on this.
In summary, the court made a judgment in accordance with the law, and the defendant insurance company of compensated Li's relatives with 150,000 yuan in insurance. After the verdict of , neither party appealed.
Judge reminds
When recommending that the public buy insurance:
1 need to clarify the needs. Analyze your own situation rationally and select appropriate insurance according to your personal needs. When buying insurance, do not blindly follow the trend, refuse to "follow the crowd" and "believe in the sidelines" and "believe in the sidelines" and choose insurance companies and types of insurance that are trustworthy and have high-quality services.
2 You should carefully study the insurance terms before signing the insurance contract. Do not sign a confirmation letter before you understand the content of the contract clearly. When signing an insurance contract, pay special attention to the standard terms in the contract, especially important terms involving protection liability, exclusion liability , claims, etc., read carefully and review carefully, and require insurance companies to explain the questions in a timely manner and fully explain them.
3 During the process of signing an insurance contract, answer the inquiries from the insurance company truthfully and objectively fill out the health status questionnaire and insurance policy .
After an insurance accident occurs, the insured shall promptly call the police or report the case, and provide objectively provided certificates and information related to confirming the nature and cause of the insurance accident involved in the case, so that the insurance company can determine the nature and liability for the insurance accident.
Recommended insurance companies:
1: Strictly regulate business behavior, carry out business activities in accordance with the law, and protect the legitimate rights and interests of insurance consumers in accordance with the law.
2. We must strengthen the management of insurance sales personnel, fulfill the obligations of prompting and clear explanation of disclaimer clause in accordance with the law, and maximize the protection of the insured's right to know and right to choose.
Third, for insurance contracts concluded through electronic insurance, the online insurance process set by the insurance company should be as comprehensive and complete as possible, and the disclaimer clauses should be prompted and clearly stated; the operation steps should be clarified, and the insured identity authentication system and electronic authentication system should be improved.
Insurance companies shall bear insurance liability in accordance with the insurance contract, and shall not artificially expand the insured's contractual obligations. For clauses involving exemption of insurance companies' liability, the obligation to prompt and explain should be fulfilled, otherwise it will not be legally binding on the parties.
Comprehensive: Yuanjiang Municipal People's Court, Hunan High Court
Source: Shandong High Court
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