This is my 74th original content in 2022.
Claims for major diseases often have stricter diagnosis conditions, including surgical requirements, pathological reporting requirements, treatment methods requirements, and autonomous living ability requirements...
We can understand this as a way for insurance companies to determine the severity of our disease.
But as our medical level improves, many treatment methods have developed in a transformative way. Do we still have to use the critical illness insurance clauses from several years ago to judge "major diseases"?
This is a very easy-to-occur claim dispute. I have dealt with a lot of them before. Let me share one of the cases with you below.
September , Jiang took out PICC Life Insurance Worry-free Life Major Disease Insurance. The terms stipulate the claims conditions for "Type I Diabetes":
must meet the following at the same time: (1) You must continue to rely on exogenous insulin to maintain your life for at least 180 days. (2) The results of blood insulin measurement, blood C peptide measurement or urine C peptide measurement are abnormal. (3) One or more of the following three complications occur: ① Complex proliferative retinopathy; ② Complex heart disease and must be implanted in a pacemaker for treatment; ③ At least one toe has gangrene and has reached the indication of surgical resection.
September 2019 , Jiang was diagnosed with "type I diabetes" through the hospital,
May 2020 , Jiang was diagnosed with left eye uveitis and type I diabetes through the hospital.
August , Jiang Mou diagnosed binocular uveitis and type I diabetes through the hospital.
Insurance company believes that The "type I diabetes" that Jiang suffered from did not meet the claims conditions in the terms , so he refused to pay the critical illness insurance premium. The "Type I Diabetes" stipulated in the clause
requires three conditions to be met at the same time, but Jiang only met one, so he was rejected by the insurance company!
In the final analysis, the way of disease treatment is determined by the doctor based on the actual condition and the development of medical means.
In order to apply for insurance company claims, we don’t listen to the doctor’s advice and seek medical treatment completely according to the insurance terms.
According to Article 21 of the "Health Insurance Management Measures",
"The disease diagnosis standards agreed by the insurance company in the terms of the health insurance product shall comply with the prevailing medical diagnostic standards and take into account the trend of the development of medical technology conditions. After the health insurance contract takes effect, if the insured is confirmed to be a disease based on the prevailing medical diagnostic standards, the insurance company shall not refuse to pay the insurance premium on the grounds that the diagnostic standards do not match the agreement of the insurance contract."
According to the general understanding and general understanding of the insured and the public, the "type I diabetes" that Jiang suffered from should belong to the category of major diseases, which is in line with the expected benefits of the insured.
In fact, the diagnosis of the disease is quite interesting. Some of
should not be compensated, while others should be compensated.
This depends on many factors such as disease diagnosis, medical record description, treatment method and subsequent rehabilitation.
At this point, the types of diseases are complex and numerous, and the specific situation needs to be analyzed in detail. If you have any insurance issues, you can leave a message.
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