The quarantine certificate used by the insurance company for claims has changed again and again, and the insured does not know how to find the relevant unit to issue a certificate to apply for compensation
"China Science and Technology Investment" Zhang Ting Yang Yongjie
Recently, several insured told reporters that he purchased accident insurance for the new coronavirus at Fosun United Health Insurance Co., Ltd. (hereinafter referred to as "Fosun United Health Insurance"), but was repeatedly rejected when applying for claims. According to the policyholder, Fosun United Health Insurance does not recognize the official quarantine certificate, and has also asked the insured to provide different proof materials many times, which makes people question whether the claims conditions are transparent.
reporter learned that the insurance product is an accident insurance developed by Fosun United Health Insurance that covers the liability for COVID-19. The publicity page also shows that "you can compensate at home", but as of now, more than 160 policyholders have encountered problems in claims settlement. According to data, from 2017 to 2020, Fosun United Health Insurance suffered losses for four consecutive years, with a total loss of 245 million yuan. In 2021, the company's net profit was 200 million yuan, turning losses into profits.
claims standards are different
In November last year, Chen Jing (pseudonym) purchased the "Fosun United Love-Wu Accidental Injury Insurance" at Fosun United Health Insurance. The policy shows that the insured can apply for compensation for the new coronavirus pneumonia diagnosis allowance and mandatory isolation allowance if it meets the conditions. However, Chen Jing's subsequent claims process was not going smoothly.
"Fosun United Love Worry Accidental Injury Insurance" policy, Chen Jing provides
Because there are people infected with the new coronavirus in the community, Chen Jing's community has been maintained at the "stay without leaving home" from March 25 until it ends on May 25. In early April, two positive cases of COVID-19 occurred in Chen Jing's building, and Chen Jing became a close contact and was asked to be quarantined at home.
On April 4, Chen Jing issued a home isolation certificate on the "Suishenban" mini program to apply for daily allowance insurance during the mandatory quarantine period. Subsequently, Fosun United Health Insurance staff called back and said they did not approve of the material and suggested that the insured collect more quarantine evidence first, or wait for the end of the epidemic, and the insurance company's policies may change.
It is worth noting that the Shanghai Higher People's Court once issued a document stating that the home health monitoring certificate submitted by the insured person through the designated online platform designated by the relevant government agencies such as "Suishenban" can be used as evidence to prove that he is quarantined; if the insurer believes that the occurrence or start or end time of the insurance accident is false, he should provide corresponding evidence. On May 6, Chen Jing made the second claim application on Fosun United Health Insurance’s WeChat official channel, and provided quarantine certificates, Shanghai Higher People’s Court, and other relevant explanation evidence. On May 11, Chen Jing received a notice that the insurance company would not pay compensation, because the existing information could not confirm that the insured met the claims conditions.
* "Notification of compensation" provided by Chen Jing
Chen Jing found a previous successful case of claims on the online platform, and a policyholder provided him with a template for the mandatory isolation proof material and stated that he successfully applied for compensation through the proof material. According to the information, the mandatory isolation proof materials are necessary for the application of claims for the "Fosun United Love Wuyou Accidental Injury Insurance" isolation allowance. They recognize the formal isolation proof materials provided by governments at all levels, health committees, streets, management committees, and neighborhood committees. The materials need to include clear identity information of the person being quarantined, the reason for the isolation, the start and end time of the isolation, the location of the isolation and the official seal.
On May 18, Chen Jing submitted the isolation certificate issued by the neighborhood committee to the insurance claim channel according to the above template, and received a reply again on May 19. This time, she needs to provide again the supporting documents issued by the Epidemic Prevention Office that were tracked as close contact with new crown patients.In addition, on May 27, another policyholder provided the reporter with the claims reply he received. The insurance company required that in addition to providing the above materials, it also required to include the corresponding centralized isolation certificate and a statement of the reasons for the failure to centralized isolation.
*The above picture is the supplementary materials needed by Chen Jing, and the following picture is the supplementary materials needed by another policyholder
What Chen Jing puzzled Chen Jing was that the same insurance product had similar situations and the forced isolation proof materials provided contained the same elements. Why did the claims standards of the insurance company change again and again? An Guangyong, an expert of the Credit Management Committee of the All-Union Mergers and Acquisition Association, told the reporter of "China Science and Technology Investment" that in the early stage, there are many difficulties in claims settlement and corresponding adjustments are needed. "From the standpoint, there are conflicts of interest between consumers and insurance companies themselves. Therefore, the entire claim settlement must be conducted entirely based on the objective spirit of contract, rather than through subjective sensibility, humanization and other subjective."
Beijing Yingke (Shanghai) Law Firm lawyer Huang Dan told reporters that under the current epidemic situation, the insurance company's fee rate has been broken down and faces high losses. Therefore, insurance companies are reluctant to pay compensation and tighten the claims caliber. "We have seen the same claims materials submitted to insurance companies on different dates, but have completely different claims results."
In response to the insurance company's situation where the insured person requires the insured to submit materials multiple times, Huang Dan said that the behavior does not comply with Article 22 of the Insurance Law. If the insurer believes that the relevant proof and information are incomplete in accordance with the contract, he shall promptly notify the insured, the insured or the beneficiary to provide additional information in one go.
Unreasonable refusal to compensate caused controversy
Information shows that "Fosun United Love-Wu You Accident Injury Insurance" is an accident insurance developed by Fosun United Health Insurance covering the liability for COVID-19. The product was launched in 2020. When it was initially launched, the insurance product included a maximum coverage of 500,000 yuan for deaths in confirmed COVID-19, as well as a medical isolation allowance of 100 yuan per day for the new coronavirus, up to 30 days. At that time, the minimum premium was 78 yuan/year.
*The left picture shows the 2020 insurance product promotion page, and the right picture shows the 2021 insurance product promotion page
Last year, Chen Jing spent 43 yuan when purchasing the insurance. The promotional page shows that he can expand the compensation for compulsory isolation allowance of 200 yuan/day, up to 30 days. In addition, the compensation for the diagnosis allowance of mild or ordinary new coronavirus pneumonia is 1,000 yuan, and the compensation for severe or critically ill patients is 3,000 yuan. After that, the insurance price has risen to 59 yuan. At present, "Fosun United Aiwuyou Accidental Injury Insurance" has been removed from the shelves.
Chen Jing told reporters that she saw the "Fosun Rights Protection Group" on the social platform, so she applied to join. As of now, there are more than 160 people in the group. In this rights protection group, most of the insured persons are forced to be quarantined at home or centralized quarantine due to the epidemic, and a small number of people are quarantined in the hospital due to infection with the new coronavirus.
An insured was previously infected with the new coronavirus and has been discharged from the hospital. When discharged from the hospital, he issued a "release of isolation" in the temporary hospital, which showed "positive nucleic acid test and new coronavirus infection". The agent of Fosun United Health Insurance told the insured that he needed to issue a certificate with the disease classification (such as mild symptoms, severe symptoms, etc.) before he could compensate for the diagnosis allowance and isolation allowance.
In this regard, Huang Dan said that according to the ninth edition of the "Diagnosis and Treatment Plan for the New Coronavirus Pneumonia" released by the National Health Commission, positive nucleic acid test for the new coronavirus is a confirmed case, and customers should receive a compensation allowance. Huang Dan believes that "the classification of 'light or ordinary type' and 'heavy or critical type' stipulated in the insurance company's contract is a distinction between the amount of compensation and the amount of compensation, but it is by no means a distinction between compensation and non-compensation. When the customer cannot provide the classification of the disease, the insurance company should first pay according to the light type, and it is by no means a rejection because it cannot provide the relevant classification certificate."
Huang Dan suggested that policyholders can try to go to the regulatory authorities to complain, such as the China Banking and Insurance Regulatory Commission, etc., and go further, they can also try litigation methods. For litigation in personal insurance, they can choose to sue in the court where they live to facilitate their rights protection.
industry insider Wu Zhongyan told the reporter of "China Science and Technology Investment" that when purchasing "quarantine insurance" products, policyholders must keep their eyes open and see the terms and regulations. They should not only believe in the advertising that is "eye-catching", but also have the mentality of "spendless money and buying peace of mind." As an insurance product promotion platform, it should also be people-centered, uphold the principle of maximum integrity, and objectively recommend products to the insured, and do not damage the image of the insurance industry due to immediate interests.
information shows that Fosun United Health Insurance was established in 2017 and was jointly initiated and established by six shareholders including Shanghai Fosun Industrial Investment Co., Ltd., Guangdong Yihua Real Estate Development Co., Ltd., Ningbo Xizi Asset Management Co., Ltd., and Chongqing Dongyin Holding Group Co., Ltd., and its main business scope includes health insurance business, accidental injury insurance business, etc.
2017-2020, Fosun United Health Insurance suffered losses for four consecutive years, with a total loss of 245 million yuan. In 2021, Fosun United Health Insurance's operating income was 3.242 billion yuan, a year-on-year increase of 47.95%; net profit was 200 million yuan, turning losses into profits.
Fosun United Health Insurance stated in its annual report that the products operated by the company are health insurance and accident insurance products, and business income is mainly divided into individual insurance and group insurance according to the type of insurance. In 2021, the company's personal insurance premium income was 3.232 billion yuan, a year-on-year increase of 66.85%. The health insurance and accident insurance revenue among personal insurance were 3 billion yuan and 223 million yuan, a year-on-year increase of 58.11% and 547.22% respectively.
In response to the problems of Fosun Health Insurance product claims and accident insurance premium income, the reporter wrote to the company, and no reply was received as of press time.
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