Health insurance dispute

The media reported a news that an old lady was insured by an insurance company? TK universal insurance (20 15) protection plan? The insurance amount is 6,543,800 yuan. From March 2065438 to March 2009, the old lady was admitted to hospital because of sudden syncope, and was diagnosed as cardiomyopathy, frequent ventricular premature beats (originating from the septum of right ventricular outflow tract and right ventricular regulating bundle) and ventricular fibrillation. During the hospitalization, the old lady had sex? ICE ultrasound catheter guided radiofrequency ablation? And implanted a pacemaker, and was once issued a critical notice. She spent more than 270,000 yuan on medical expenses. After leaving the hospital, the old lady applied to the insurance company for compensation, but the insurance company used it? Does not meet the standard of severe cardiomyopathy agreed in the insurance contract? Reasons for refusing the claim. Therefore, the old lady sued an insurance company to the court, demanding that an insurance company bear the insurance liability and pay insurance compensation of 6,543,800 yuan. At present, most people are insured with relevant insurance, and many people encounter various problems in the process of claim settlement. So similar? Seriously ill? Who is in charge of this clause?

1, insurance company's explanation.

In this case, the insurance company's defense is that the hospital medical records provided by the old lady can't prove her pain? Cardiomyopathy? Meet the insurance contract? Severe cardiomyopathy? Situation, and the terms of the insurance contract have been? Severe cardiomyopathy? The specific definition is given, and the disease characteristics of insurance clauses and medical records are not consistent. Therefore, the old lady's illness does not fall within the scope of insurance liability, and the insurance company refuses to bear the insurance liability. But the court held that? Severe cardiomyopathy? It is a major disease that insurance companies choose to underwrite and define by themselves. Will the insurance contract? Severe cardiomyopathy? Defined as? The left ventricular cavity enlargement reaches at least 120% of the upper limit of normal value and the left ventricular ejection fraction remains below 40%? It obviously exceeds the expectations of ordinary people when concluding the contract, and the insurance company is concerned about this clause? Special restrictions? Not fully explained and clearly prompted. Therefore, this clause is invalid and the insurance company should compensate.

2、? Seriously ill? Standard.

Insurance institute of china and Chinese Medical Doctor Association jointly formulated China's first "Criteria for the Definition and Use of Diseases in Critical Illness Insurance", which clearly stipulated the coverage of critical illness insurance products for people aged over 18, and must cover malignant tumors with the highest incidence and claims rate among 25 major diseases (excluding some early malignant tumors); Acute myocardial infarction; Sequela of cerebral apoplexy (permanent sexual dysfunction); Major organ transplantation or hematopoietic stem cell transplantation (allogeneic transplantation); Coronary artery bypass grafting (or coronary artery bypass grafting, which requires thoracotomy); End-stage renal disease (or uremia stage of chronic renal failure, requiring dialysis treatment or kidney transplantation). In addition to these six diseases, the insurance company can choose whether to use other diseases within the scope of this specification, but the diseases selected by the insurance company should meet the medical standards. Articles 22 and 23 of the Measures for the Administration of Health Insurance clearly stipulate that insurance companies should respect the insured's right to receive reasonable medical services when formulating medical insurance products; The agreed diagnostic criteria for diseases should conform to the prevailing medical diagnostic criteria. In addition, the obligation to explain the terms of the contract format should be fulfilled.