According to the definition of the “Health Insurance Management Measures” (Order No. 3 of 2018 of the China Banking and Insurance Regulatory Commission), health insurance refers to the insurance that the insurance company pays insurance money to the insured due to health reasons or medical behaviors. Subdivided into medical insurance, sickness insurance, disability income loss insurance, nursing insurance, and medical accident insurance. As a type of insurance that is closely related to personal health, disease insurance must be designed and implemented in conjunction with medical technology. With the evolution of medical technology, in the process of cooperation between medical institutions, medical institutions and insurance companies, product innovation has been intensified, and many problems have arisen in the process of exploration.
For disease insurance (such as critical illness insurance), insurance companies usually limit the medical means, that is, the insured can only use the medical means agreed in the insurance contract for treatment, otherwise the insurance company will not pay. On the one hand, after the insured person is diagnosed, which medical method to choose is usually determined by the medical institution based on professional knowledge. The medical method agreed in the insurance contract may not be fully applicable to some insured persons. It may be different from the agreement in the contract; on the other hand, the protection period of long-term health insurance lasts for several years or even decades, and the medical methods agreed in the insurance contract may have been eliminated in practice, so the change of medical technology is also an important aspect of the insurance contract. great challenge.
Then, the insurance company stipulates in the insurance contract that it only pays for the expenses incurred by the medical treatment under the contract. Can this clause be supported by law? After analyzing judicial precedents, there are different views in practice.
(1) Viewpoint 1: Clauses restricting medical means in insurance contracts are invalid
Article 19 of the “Insurance Law” stipulates: “The following clauses in an insurance contract concluded with the standard clauses provided by the insurer are invalid: (1) exempting the insurer from the obligations that the insurer should bear according to law or increasing the liability of the policyholder or the insured; 2) Excluding the rights enjoyed by the policyholder, the insured or the beneficiary according to law.”
From this point of view, sickness insurance refers to the insurance that provides protection for the insured when the disease stipulated in the insurance contract occurs. Restricting medical means in China actually restricts the right of the insured to obtain claims by limiting the treatment method, and transfers the responsibility of the insurance company to control risks to the insured, which increases the responsibility of the insured and exempts the insurance company from its obligations. Article 19 of the “Insurance Law” stipulates that such agreements are invalid. Supporting cases such as:
- Wang Mou v. a life insurance company Huai’an City Chuzhou branch company insurance contract dispute published in the “Supreme People’s Court Gazette” No. 12, 2015
The court held that the insurance company restricted the insured’s right to claim settlement by restricting treatment and exempted itself from insurance liability. According to the provisions of Article 19 of the “Insurance Law”, this clause is invalid.
- (2022) Ji 06 Min Zhong No. 4280 Life Insurance Contract Dispute
The court of second instance held that, for the insured or the insured, the purpose of signing life insurance is to obtain compensation after the treatment of a major disease, and the insured has the right to choose a treatment method according to his own physical condition. With the development of medical science and technology, patients suffering from hyperprolactinemia and pituitary prolactinoma do not necessarily need surgery or radiation therapy, and the purpose of treatment can also be achieved by taking bromocriptine. The insurance company restricts the insured’s right to obtain insurance compensation by restricting treatment methods such as “actually receiving surgery or radiation therapy”. In fact, the fulfillment of specific obligations is a prerequisite for underwriting risks, which is a hidden obligation clause. The responsibility of the insurance company to control risks is transferred to the insured, which aggravates the legal obligation of the insured and should be invalid.
- (2022) Yu 16 Civil Final No. 4980 Personal Insurance Contract Dispute
The court of first instance held that although the insurance contract expressly stated the necessary conditions for coronary artery bypass grafting (or called coronary artery bypass grafting), it included coronary artery stent implantation, cardiac catheter balloon dilatation, laser radio frequency technology and other Thoracic interventional surgery and laparoscopic surgery are excluded from the coverage. Major diseases and major disease treatment methods are two different concepts. The insurance purchased by the insured is critical disease insurance, and non-critical disease treatment insurance. Coronary artery stent implantation is only a medical method for the treatment of some heart diseases. If the insured suffers from a heart disease, what kind of medical treatment to take is determined by the medical institution based on the patient’s condition, not the patient’s decision. Due to the characteristics of the insurance contract, there is a serious asymmetry between the insurer and the policyholder in terms of information, experience and knowledge of the insurance business. When the parties to an insurance contract have disputes over the interpretation of the contract content, ordinary people’s reasonable understanding of the purpose of the contract should be used. Look forward to interpreting the insurance contract as a starting point. Judging from the symptoms, treatment, etc. of the insured’s illness, this case is a major illness understood by ordinary people, and it also meets the insurance intention and reasonable expectations of the insured who does not have medical and insurance professional knowledge. The insured has the right to request Insurance company claims.
The court of second instance further clarified that although the operation performed by the insured was coronary artery stent implantation, the choice of treatment method is constantly changing with the development of medical technology and the patient’s own condition, so it does not support the insurance company’s refusal of compensation claim.
(2) Viewpoint 2: The clause restricting medical means in the insurance contract is legal and valid, and the insurance company can refuse to pay for it accordingly
This view holds that the insurance company’s limitation of medical means in the insurance contract of disease insurance is an agreement on insurance liability, that is, the insurance company only bears the insurance liability for a certain type of disease under the agreed medical means, and this agreement is not an exemption clause. If the company fulfills its obligation of prompting and explaining the standard clauses, the restrictive agreement is legal and valid, and the insurance company has the right to refuse compensation when the insured adopts treatment methods other than those agreed in the contract. Supporting cases such as:
- (2018) Shaanxi 05 Minzhong No. 65 Insurance Contract Dispute
The court held that the insurance contract involved in this case was legal and valid. The contract clearly expresses the compensation standards for major diseases and various diseases. The insured was diagnosed with left temporal arachnoid cyst, which belongs to the special disease of brain cyst stipulated in the contract. The compensation condition of this article is “diagnosed and actually received surgery or radiation therapy”, while the insured received conservative treatment If the conditions for early payment of insurance benefits and premium exemption as agreed in the contract are not met, the insurance company may refuse to pay.
- (2018) Jing 04 Min Zhong No. 167 Personal Insurance Contract Dispute
The court of second instance held that the insurance contract stipulated that “it was diagnosed as a pituitary tumor or brain cyst by cranial tomography (CT), magnetic resonance (MRI) or other imaging examinations, and actually received surgery or radiotherapy”. The agreement on the scope of insurance liability is not a clause exempting the insurer from liability. The insured’s claim that the clause exempts the insurance liability by limiting the treatment method should be an invalid clause’s appeal opinion, which lacks factual and legal basis, and this court does not accept it.
(3) Thoughts and Suggestions
Such cases and disputes mainly exist in critical illness insurance, and the courts are divided on whether insurance companies can limit medical treatment.
Although Article 2 of the “Health Insurance Management Measures” defines disease insurance as “insurance that provides protection for the insured in the event of a disease stipulated in the insurance contract”, the China Insurance Association’s “Specifications for the Use of Disease Definitions for Critical Illness Insurance (Revised in 2020″) )” (hereinafter referred to as the “Usage Specification”) stipulates: “The term ‘disease’ in this specification refers to the disease, disease state or operation stipulated in the critical illness insurance contract.” , for the insured’s disease, disease state or surgery, the insurance company’s non-insurance liability shall not exceed the scope specified in 3.2 of this specification.” “3.2 The exclusion of critical illness insurance is due to one of the following circumstances, The insurance company shall not bear the insurance liability if it causes the insured to suffer from a disease, reach a disease state, or undergo surgery…”, the major diseases listed in the “Usage Specifications” include major organ transplantation or hematopoietic stem cell transplantation, coronary artery bypass grafting (or Coronary artery bypass grafting) and other operations, such as the coronary artery bypass grafting (or coronary artery bypass grafting) disputed in the aforementioned (2022) Yu 16 Minzhong No. 4980 personal insurance contract dispute case, the “Usage Specification” It also clearly excludes coronary artery stent implantation, cardiac catheter balloon dilatation, laser radio frequency technology and other non-thoracotomy interventional operations and endoscopic operations from the scope of protection. Judging from the aforementioned regulations, the “Health Insurance Management Measures” does not define the scope of “disease”, while the industry standard for major diseases defines in detail. The “disease” in the industry standard for major diseases includes diseases understood by ordinary people. , also including surgery.
We understand that one of the important reasons why the court does not support the insurance company’s refusal of compensation based on medical means is that it has a relatively narrow understanding of what is meant by the “disease” stipulated in the insurance contract, which may also be different from the current general expression of the insurance industry on disease insurance clauses There is a certain connection.
At present, the more common insurance liability expression in the industry is: “The insured is diagnosed for the first time by the hospital and suffers from the major disease (no matter one or more) stipulated in this contract due to accidental injury, or the insured is diagnosed for the first time by the hospital after the waiting period. If you suffer from a major disease (no matter one or more) defined in this contract due to accidental injury, the insurer will pay the major disease insurance benefit to the beneficiary of the major disease insurance benefit according to the insured amount of this contract. After the insurer pays the insurance benefit, The insurance liability of this insurance contract is terminated.” Judging from the above statement, it may indeed cause ordinary people to think that the so-called disease does not include surgery.
Therefore, in order to better integrate insurance products and medical technology, ensure that treatment methods are reasonably connected with insurance liabilities, and reduce relevant legal risks, it is recommended that insurance companies refer to the “Usage Specifications for Disease Definitions of Critical Illness Insurance (2020) when drafting insurance clauses.” Revision) “, clearly defined the disease: “The disease stipulated in this insurance contract refers to the disease, disease state or operation stipulated in the insurance contract”, and, in the liability clause, exclusion clause and other clauses of the insurance clause, all Expressed as “suffering from a contractually agreed disease or undergoing a contractually agreed surgery” or similar.
For further information, please contact:
Yu Dan , Partner, Anjie Broad