The content design of the critical illness insurance clause for insurance companies is based on the insurance and medical knowledge system. It will define the "critical illness" in the scope of insurance liability through the type or name of the disease, severity or status, and treatment methods, thereby clarifying the "what to be covered" and "what not to be covered". However, the definition of black and white text will still be "disconnected" from the actual clinical medical system, and the resulting differences in the understanding of claims conditions and even claims disputes occur frequently.
Today, let’s share a case of claims disputes arising from “diagnostic standards”.
case background
In December 2019, Mr. Huang, whose daughter, under 4 years old, had no obvious causes, such as dry mouth, , drinking more, urinating, eating more, easy hunger, and itchy skin throughout the body. Mr. Huang took his daughter to the local Chinese medicine hospital for treatment, and was later diagnosed with " diabetic ketoacidosis , type 1 diabetes, and bronchitis". After being discharged from the hospital, Huang Yueyue continued to receive insulin injection treatment. In August 2020, Mr. Huang filed a claim application; on September 7, the insurance company issued a "claim settlement report" to refuse to pay the major disease insurance premium on the grounds that "this claim application did not meet the standard of major disease payment, and the case refused to pay, and the contract will remain valid after this claim."
After the insurance company refused to pay compensation, Mr. Huang negotiated and negotiated with the insurance company many times, but the insurance company still insisted on the conclusion of refusal. In desperation, Mr. Huang found the claim assistance consultation through the Internet and entrusted the claim lawyer to join the claim to represent the case.
Trial Documentation
During the trial, the insurance company, as the defendant, argued that it should not bear the liability for critical illness insurance payment. The reason is:
1. The plaintiff provided the test results of a medical laboratory to indicate three diabetic autoantibodies. The laboratory is not a medical institution, and the test results cannot confirm that the plaintiff was diagnosed with type 1 diabetes.
2. When applying for the claim, the plaintiff did not provide evidence that his persistent dependence on extrovert insulin was maintained for more than 180 days. The insured was discharged from the hospital on December 30, 2019 to test that the fasting blood sugar was 3.9mmol/L, which did not meet the clinical diagnosis standards for diabetes .
3.C peptide examination is a more effective indicator for diabetes typing in clinical practice, but there is no C peptide examination report in the claims materials provided by the plaintiff, and the basis for compensation for type 1 diabetes is insufficient.
In court, in response to the defendant's defense, the lawyer who settled in the claim assistance pointed out:
First of all, because the traditional Chinese medicine hospital does not have the equipment conditions for this examination, the traditional Chinese medicine hospital commissioned a medical examination laboratory to conduct the examination, and the traditional Chinese medicine hospital made the final diagnosis in combination with the report of the medical laboratory. The Chinese medicine hospital was the Chinese medicine hospital, not the medical laboratory, and the hospital was a Class A Chinese medicine hospital, the diagnosis department was the "diabetes department" and the diagnosis doctor was "Doctor Wei Moumou". It also provides one piece of evidence of the hospital's qualifications and doctor's qualifications, proving that the hospital is a Class A Chinese Medicine Hospital from March 2014 to the present; Dr. Wei has been engaged in clinical work in the Diabetes Department of the hospital since 2010 to the present. He has the valid "Doctor Qualification Certificate" and " Doctor Practice Certificate " and has registered with the relevant departments on time. On June 2, 2019, he obtained the valid "Doctor Professional Title Certificate" of the attending physician of the People's Republic of China.
Therefore, hospitals, doctors and diagnosis departments all meet the requirements of the insurance contract for "hospitals", "doctors" and "confirmation departments" for critical illnesses.
Secondly, the treatment opinion column in the disease diagnosis certificate issued by the Chinese medicine hospital records that "the patient was hospitalized in our hospital from December 27, 2019 to December 31, 2019. He is now clearly diagnosed with type 1 diabetes and requires long-term subcutaneous insulin injection for treatment." After being discharged from the hospital, Huang Yueyue followed the doctor's advice and went to the hospital for re-examination on January 20, March 23, April 4, June 8, June 30, August 3 and October 8, 2020. Since the discharge, the plaintiff has been continuously injecting insulin every day to control blood sugar to maintain blood sugar balance. It is enough to prove that Huang Yueyue has been continuously dependent on insulin injection for more than 180 days.
Third, the defendant's insurance contract terms formulated for "insulin-dependent diabetes", that is, "Insulin-dependent diabetes is a chronic increase in blood sugar caused by the absolute lack of insulin secretion caused by the destruction of pancreatic β cells, and requires continuous dependence on exogenous insulin for more than 180 days. The disease must be diagnosed with by the endocrinologist in the hospital. Diabetes that can be treated with other methods (non-insulin injection) are not covered by the coverage of this contract." This definition does not stipulate that a C-peptide examination must be performed for . The plaintiff's blood sugar measurement the day before discharge is the result of blood sugar monitoring after treatment, and it is not cured.
(Insulin-dependent diabetes in the contract)
In summary, Huang Yueyue's condition meets the definition of "insulin-dependent diabetes" in the insurance contract, and the insurance company should bear the responsibility for paying critical illness insurance.
Judgment Results
The first instance court adopted the opinion of the plaintiff's attorney. The main text of the judgment is as follows:
This court's opinion: Regarding the defendant's defense that the plaintiff did not meet the claims standard, he did not provide a C peptide examination report, and it is impossible to confirm that the plaintiff has type 1 diabetes, and the defendant should not pay the plaintiff's insurance money. After investigation, it was found that the plaintiff was the insured person in the insurance contract involved. He fell ill during the insurance period and was diagnosed with the major disease "type 1 diabetes" (i.e., insulin-dependent diabetes) under the contract stipulated in the insurance contract. The plaintiff has been dependent on insulin injection for more than 180 days since he was admitted to the hospital and cannot be treated with other methods (non-insulin injection). It fully complies with the insurance contract's agreement on the disease, and the insurance contract does not stipulate that a C-peptide examination must be performed. The plaintiff's blood sugar measurement the day before discharge was the result of his blood sugar monitoring after treatment, and it is not cured.
Therefore, this hospital determined that the plaintiff diagnosed by the county traditional Chinese medicine hospital was "type 1 diabetes". The disease belongs to the scope of major diseases covered by the insurance contract, and the defendant shall pay the plaintiff the major disease insurance premium in accordance with the contract. The defendant's above defense is not valid and this court will not adopt the defense.
Main text of the judgment: The defendant insurance company pays the plaintiff's major illness insurance premium RMB 500,000 within ten days from the date of the effectiveness of this judgment.
(first instance judgment result)
The defendant insurance company appealed the first instance judgment. The second instance court upheld the original judgment. The insurance company in this case has now executed the verdict content in and has paid Mr. Huang 500,000 yuan in insurance.
(Second instance judgment result)
A little helper commented
As a policyholder, if you encounter a similar situation of refusal to compensate, don’t blindly complain that the insurance company refuses to compensate, but you don’t need to give up your claim right easily. You should consult a professional doctor and insurance lawyer to evaluate whether the actual disease is consistent with the disease stipulated in the terms and whether it is reasonable to refuse to compensate.
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