There are several cases about compensation and non-compensation of congenital diseases, which can be used for reference.
■ Case 1:
1996 requires students to pay insurance premiums in 25 yuan, including student safety insurance 10 yuan and additional illness insurance 15 yuan. However, a few days after paying the money, Xiao Zuo was admitted to the hospital because of congenital diseases. Later, Zuo's father asked the insurance company for reimbursement of medical expenses, and the insurance company found out a clause of "additional insurance for students' safety", which did contain clauses except congenital diseases. The two sides could not reach an agreement, so they sought a legal solution.
The court held that the Insurance Law stipulates that if there is an insurer's liability exemption clause in the insurance contract, the insurer shall clearly explain it to the insured when concluding the insurance contract. If it is not clearly stated, this clause will not take effect. However, when the insurance company entrusted the school to handle the "student safety additional insurance" business, it did not fulfill its obligation to inform, so the exclusion of liability was invalid. The court finally ruled that the insurance company should pay compensation to the plaintiff within 10 days after the judgment came into effect.
■ Case 2:
In 2000, Ms. Xie purchased term life insurance and additional medical insurance from an insurance company. Five years later, Ms. Xie was diagnosed as "right parasellar cavernous hemangioma". When she went to the insurance company to claim compensation, the insurance company refused to pay compensation on the grounds that the congenital disease was within the scope of liability exemption, and based on an academic discussion article, it proved that the disease was congenital.
Ms. Xie refused to accept that any disease has congenital factors, and she was not required to have a physical examination when she was insured. This should be regarded as the insurance company's recognition that Ms. Xie is healthy and meets the insurance conditions.
It is understood that the case finally reached an agreement through mediation, but the specific details are not clear.
■ Case 3:
Ms. He bought old-age security from an insurance company in 2002, but when she suffered from ovarian cyst in 2006, she claimed compensation from the insurance company, but it was rejected. The reason of the insurance company is that the hospitalization of the insured due to congenital diseases is an exemption clause, while Ms. He's mediastinal uterus belongs to congenital benign diseases, which naturally does not belong to the scope of claims.
Ms. He believes that its congenital diseases are not directly related to ovarian cysts. For example, one day someone went to the hospital for examination and found that he had stomach cancer. It can't be said that some people can understand that treating stomach cancer is treating stomach pain, so they don't pay compensation. This explanation doesn't make sense. The insurance company immediately offered a discretionary compensation of 2,000 yuan, but Ms. He was not satisfied. Comments:
There are various insurance cases caused by congenital diseases. The experience of Xiao Zuo in the first case is instructive to many people who buy group insurance. That is to say, as long as it can be proved that the insurance company has not fulfilled its obligation to inform, even if the insurance clause has the clause of "no compensation for congenital diseases", the insured can still get claims according to law.
But for citizens who buy life insurance in daily life, most of them take the marketing agency channel. After signing the application form and service confirmation form, it is basically unrealistic to prove that the insurance salesman did not fulfill the obligation of informing at that time. In the event of a compensation dispute, both the insurance company and the insured may need to provide evidence. In the absence of a unified definition, who can find more authoritative arguments to prove the nature of the disease may have an impact on the final court decision.
After all, it is exhausting to resort to legal channels. If you want to bury hidden dangers when paying compensation, it is best for citizens to read the terms clearly when they apply for insurance, especially the exclusion liability. Even if the insurance company does not require a physical examination, it should go to the hospital for a general examination in time, and take the diagnosis as the most powerful proof that there is no related congenital disease.
In the end, citizens who refuse to pay for congenital diseases may still be somewhat dissatisfied even if they accept this decision, because it seems to confirm the public's complaint that insurance is "easy to get on and difficult to get off". In fact, some overseas areas have begun to make humanized adjustments, such as "as long as it is the first time, even congenital diseases can be compensated", and the exemption clause also deliberately lists, that is, how many kinds of congenital diseases can refuse to pay compensation, and diseases outside the clause are regarded as compensable. The definition of critical illness insurance in China has been gradually unified in recent two years, and it is believed that the compensation treatment of congenital diseases will be more and more beneficial to the insured.
Newborn goods
Completely different from the insurance clauses for adults, the insurance for newborns mostly includes the protection of "congenital diseases". Of course, the insurance must be completed before the child is born. This difference is not difficult to understand. Adults have congenital diseases when they are insured, and the risks are uncontrollable for insurance companies. The probability of babies suffering from various congenital diseases at birth is reliable, and insurance companies have reference standards when formulating insurance coverage and rates.
Therefore, when discussing newborn insurance (mainly maternal and child insurance for adults and children), congenital diseases are not a question of whether to pay compensation, but a question of what to pay, how to protect it and how to pay compensation.
When will it be insured?
At present, the vast majority of maternal and child insurance in the market needs to be purchased before pregnancy, and its coverage is set for women aged 20-40 or 45 who have legal childbearing conditions and hold a birth permit. If they plan to get pregnant and meet the requirements of insurance protection, they can buy such products. Only a few companies have special requirements on the gestational age, such as China Life Insurance, which requires that pregnancy should not exceed 16 weeks.
For families who are going to have children, if they feel that there is a need for insurance during pregnancy, it is best to insure women before pregnancy, so that the protection period can cover pregnancy. Don't wait until you are pregnant to consult and buy in a hurry. It should be noted that different maternity insurance guarantees have different protection periods for newborns, which are mainly divided into two types. One is to guarantee short-term insurance from the policy issuance to the postpartum discharge of pregnant women, and the other is to guarantee long-term insurance from the policy issuance to the baby's fifth birthday.
Protect what?
On the one hand, the existing maternal and infant insurance covers pregnant women's pregnancy diseases (disseminated intravascular coagulation, choriocarcinoma or hydatidiform mole, ectopic pregnancy), childbirth or accidental death, on the other hand, it also covers fetal or neonatal death, neonatal congenital diseases (such as spina bifida, tetralogy of Fallot, Down syndrome, congenital hydrocephalus, atrial septal defect or ventricular septal defect, complete dislocation of great vessels, esophageal atresia, esophageal-tracheal fistula, anus.
For example, China Life's "Caring for Women's Disease Insurance" pays the congenital disease insurance premium at 15% of the basic insured amount, covering 10 congenital diseases; Another example is the "Sincere Care Plus Maternal and Child Health Insurance" published by Radio and Television Daily, with an insurance period of 5 years, a one-time premium of 1708 yuan, and an insurance premium of 20,000 yuan for infant congenital diseases.
It is worth noting that even congenital diseases may not fully meet their compensation conditions because insurance companies use enumeration method when describing the liability for protection of congenital diseases. For example, the specific trisomy is only aimed at the abnormality of three pairs of chromosomes, and the specific congenital heart disease only includes nine situations.
How to pay?
When the beneficiary applies for compensation for congenital diseases, he should generally fill in the Application Form for Insurance Payment and submit the following certificates and materials: the insurance contract and the latest insurance payment certificate; Household registration certificate and identity certificate of the beneficiary; Birth certificate or household registration certificate of "accident insured" (applying for congenital disease insurance); Diagnostic certificate and relevant examination, pathological section and operation report issued by medical institutions designated or recognized by insurance companies.
When necessary, the insurance company can also review the disease diagnosis results of the insured or the "accidental insured", and the relevant expenses are generally borne by the insurance company.