The claimant of Fujian Branch of Harmony Health Insurance Co., Ltd., an insurance company that refused to claim compensation, said that the company believed that the pathological conclusion could not meet the "malignant tumor" standard agreed in the contract. Regarding why the other two insurance companies made claims, the staff said that if they refused to accept claims, it was suggested that the insured should bring a lawsuit to the court to resolve the dispute.
After finding out the intestinal cancer, I made two claims and refused to pay compensation once.
Chen Hao is 46 years old and comes from Fuzhou, Fujian. His wife, Chen Juan (not her real name), said that she had a high awareness of insurance and began to buy critical illness insurance for herself and her family in 2006. Until 2020, she successively purchased different amounts of critical illness insurance for Chen Hao in China Ping An Life Insurance Company of China Insurance Company Limited ("China Ping An Life Insurance Company of China Insurance Company Limited"), China People's Health Insurance Company Limited ("China People's Health Insurance Company Limited") and Harmony Health Insurance Company Limited ("Harmony Health Insurance Company Limited").
On July 9, 2020, Chen Hao received 300,000 yuan from China People's Insurance Company for critical illness insurance.
Among them, Harmony Health Insurance was purchased in August 20 14, and the insurance product name is "Harmony Health Regular Cancer Prevention Insurance". The first year coverage 1232 yuan, the insurance period is 20 years, and the coverage is 200,000 yuan. If the cancer is diagnosed, it will cost 200,000 yuan.
In May 2020, Chen Hao went to the hospital for gastrointestinal examination and found a small tumor in the intestine. At the beginning of July, Chen Hao completed the resection in Fujian Provincial Hospital. The pathological diagnosis issued by the hospital showed that (rectum, ESD) intestinal neuroendocrine tumor (G 1) infiltrated mucosa to submucosa, and the lateral and lower edges of the surgical specimens were not affected.
In early August, Chen Hao applied to China Ping An Life Insurance Company of China Insurance Company and China People's Insurance Company for claims. Both companies decided that the pathological diagnosis belonged to G 1 period of rectal cancer, which met the "malignant tumor" standard agreed in the contract, and made claims, with the compensation amount and medical expenses of about 2.08 million yuan.
However, when applying for compensation from Harmony Health Insurance, Chen Hao received a "rejection letter" on the grounds that "it does not constitute a compensation condition".
The paper compares the contracts of three insurance companies and finds that the expression of "malignant tumor" is consistent. "The same insurance clause, the same disease, why is there a difference in claims?" Chen Juan was surprised.
The expression of "malignant tumor" in the critical illness insurance contract of Harmony Health Insurance insured by Chen Hao's wife is consistent with that of the other two insurance companies.
Refusal to sign the company's reply: if it fails to meet the standard, it can be prosecuted if it refuses to accept it.
The description of "malignant tumor" by the three insurance companies is: "refers to diseases in which malignant cells grow and spread uncontrollably, infiltrate and destroy the surrounding normal tissues, and can spread to other parts of the body through blood vessels, lymphatic vessels and body cavities. It was clearly diagnosed by pathological examination results, and the clinical diagnosis belongs to the category of malignant tumor in the International Statistical Classification of Diseases and Related Health Problems (ICD- 10) of the World Health Organization. "
Among them, the following diseases are not covered by malignant tumors: 1) carcinoma in situ; 2) Chronic lymphocytic leukemia corresponding to stage A of Binet staging scheme; 3) Hodgkin's disease equivalent to Ann Arbor stage I; 4) Skin cancer (excluding malignant melanoma and metastatic skin cancer); 5) Prostate cancer with 5)TNM stage of T 1N0M0 or lower; Malignant tumor during HIV infection or AIDS.
The paper notes that the above expression of "malignant tumor" originated from the Specification for the Use of Critical Illness Insurance Definitions (hereinafter referred to as "Specification") issued by the Critical Illness Insurance Expert Committee of insurance institute of china and Chinese Medical Doctor Association in 2007, which is the first standardized operation guide for the critical illness insurance industry in China, standardizing the definition and degree of major diseases such as malignant tumor, so as to ensure the definition and claim standard of 25 diseases in critical illness insurance.
Earlier, some media reported that the background of the standard was that different insurance companies had different definitions of critical illness insurance, which led to different understandings between insurers and insured, and also allowed some misleading marketing behaviors to take advantage of it, leading to a large number of insurance claims disputes.
1October 29th 10, this newspaper went to Harmony Health Fujian Branch with Chen Juan to learn about the situation. The adjuster told Chen Juan that although Chen Hao's condition reached infiltration, the expression of "destroying the surrounding cells" did not exist, and the relevant claim application had been reported to the head office, which thought that the pathological conclusion could not meet the "malignant tumor" standard agreed in the contract.
As for the question that the other two insurance companies have already paid, why Harmony Health does not pay, the adjuster said that the company decided that the pathological conclusion still did not meet the standards recognized by the company. If you are not satisfied with the claim decision, you can bring a lawsuit to the court.
Harmonious health insurance Fujian branch.
For the above situation, Chen Juan also complained to the Fujian Insurance Regulatory Commission. The staff who handled the complaint said that the regulatory authorities were supervising the illegal acts of insurance companies, and the insurance companies refused to settle claims, which was a civil dispute. If consumers fail to reach an agreement with the insurance company, they can apply to the Consumer Protection Center for free mediation. If no agreement can be reached through consultation, the most effective way is to go to court for settlement.
Chen Juan said that he would continue to complain to the relevant departments and prepare to file a lawsuit in court.