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Insurance companies refuse to pay for serious illnesses How to apply the principle of "unfavorable explanation"
China Insurance News Network
On September 16, 2005, Li signed a life insurance contract with the insurance company, covering 10 kinds of serious illnesses. On December 9, 2012, the insured Li suffered from cerebral infarction, coronary heart disease and complete aphasia, which had a major impact on his body and life. At the time of the claim, the insurance company stated that the disease was not covered by the ten serious illnesses covered by the insurance contract and refused to pay compensation.
The court of first instance held that the focus of the dispute between the two parties in this case was whether the disease suffered by the insured Li was a major illness. Major diseases are not specific diseases, but an uncertain concept that is difficult to determine. As is generally understood, it should refer to a disease that is costly due to the severity of the disease and that has a significant impact on the patient as a result of the illness. Due to the uncertainty of connotation and extension, it is difficult to explain only by enumeration. Generally, there should be a clause. In this case, the interpretation of the insurance clause only lists 10 diseases as major diseases, far less than the scope of major diseases understood by ordinary people, and there is no general clause that should be included when explaining the concept of uncertainty.
According to the provisions of the Insurance Law, an insurance contract concluded by the terms provided by the insurer, if the insurer and the insured have disputes over the terms of the contract, shall explain it according to the usual understanding. If there are more than two explanations of the terms of the contract, it shall be beneficial. Interpretation of the insured and the beneficiary. Therefore, the understanding of the connotation and extension of major diseases should be interpreted in favor of Li. Judging from the hospitalization of the insured Li, his cerebral infarction and coronary heart disease have a major impact on his body and life. It should belong to the major diseases understood by the general public, which is also in line with the real wishes of the insured and a Reasonable expectations of ordinary people in society. Therefore, the insurance company should pay Li’s major illness insurance premium in accordance with the insurance contract.
Article 30 of China's Insurance Law stipulates that: “In the case of an insurance contract concluded by the terms provided by the insurer, if the insurer and the insured, the insured or the beneficiary have disputes over the terms of the contract, they shall explain it according to the usual understanding. Where there are more than two interpretations of the terms of the contract, the people's court or the arbitral institution shall make an explanation in favor of the insured and the beneficiary."
When people see this article, there will be a misunderstanding, that is, as long as there are more than two explanations of the contract terms, such as the insured or the insured has an explanation, the insurer has an explanation. This is not two explanations. This is not a different explanation. Therefore, it is considered that the court or the arbitral institution must make an explanation that is beneficial to the insured and the beneficiary.
In judicial practice, in the trial of personal insurance contract disputes, some judicial organs unreasonably prefer the insured, the insured, and the beneficiary. For this purpose, the contract terms, words, and The concept, connotation and extension are explained, even at the expense of legal justice. Such so-called "interpretation" is not an explanation, but a distortion.
This is a misunderstanding. The root cause of the misunderstanding is that I only see the phrase "there are two or more explanations for the terms of the contract." I did not pay attention to the phrase "should be explained according to the usual understanding."
What is the usual understanding to explain? Article 142 of the General Principles of the Civil Law of China stipulates: "The interpretation of the meaning of the relative person shall be determined in accordance with the words and phrases used, in combination with the relevant provisions, the nature and purpose of the act, the habits and the principle of good faith. Meaning. The interpretation of the meaning of no relative person can not be completely adhered to the words used, but should be combined with the relevant provisions, the nature and purpose of the behavior, the habits and the principle of good faith to determine the true meaning of the perpetrator. We can explain this by referring to such legal provisions.
This is the basic rule for explaining the terms of the contract and the format. How do we understand the rule? In combination with the above, I feel that at least there is such an understanding:
A. The subject of interpretation can only be a court or an arbitration institution and cannot be either party. The parties will have their own understanding, and basically understand their own interests, but it is not counted, it should be interpreted by the court and the arbitration institution;
B. The object of interpretation can only be the format clause that has been expressed, that is, the interpretation of the content of the format contract clause;
C. The purpose of the explanation is to determine the specific content of the meaning representation;
D. There are two ways to explain. If there is a relative human expression, the interpretation method is expressionism, and the main external content of the expression is mainly explained.
E. If there is no relative human expression, the interpretation method is meaning, not sticking to the words, but the actual intention of the perpetrator;
F. The explanation step is to make a reasonable explanation based on the elements of the format clause, meaning, system, purpose, habit, and integrity.
Therefore, the author believes that the provisions of Article 30 of the Insurance Law of China should be fully understood. From the provisions of this article, both paragraphs should be fully understood and applied. It should be concluded that:
First of all, the court or the arbitral institution should first explain the terms of the format contract according to the usual understanding. If the result of the interpretation is the only one that is generally understood, no matter which party is beneficial or even beneficial to the insurer, this explanation is the only explanation. The result of the referee should be determined according to this result. In this case, there is no problem that applies a disadvantageous explanation.
Secondly, the court or the arbitration institution explained the format contract terms according to the usual understanding, and found that there are more than two kinds of general understandings. The result of the interpretation is still more than two kinds, then it is impossible to draw a unique conclusion. Only at this time, It is only necessary to make an explanation that is beneficial to the insured and the beneficiary.
Only such understanding and application is fair and reasonable, and it is also in line with the law.
(The author is a partner and lawyer of Beijing Gefeng Law Firm)
Editor in charge: Li Limeng RF13188
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