cciia.org.cn 2023-3-17 10:46:58 中(zhong)國(guo)法院網
中國法院網訊（管颯爽 石玉）老(lao)李(li)(li)的女兒小李(li)(li)為(wei)老(lao)李(li)(li)投保(bao)(bao)了(le)(le)個人醫療(liao)保(bao)(bao)險，老(lao)李(li)(li)被確診肺(fei)部惡性腫瘤后向保(bao)(bao)險公司索(suo)賠，保(bao)(bao)險公司拒(ju)賠，認為(wei)投保(bao)(bao)人投保(bao)(bao)時未如(ru)實告知老(lao)李(li)(li)曾(ceng)確診虹膜缺(que)如(ru)，屬于帶病投保(bao)(bao)。近(jin)日，江(jiang)蘇省如(ru)東縣人民法院審(shen)理了(le)(le)該起保(bao)(bao)險合(he)同糾紛案件。
2021年9月(yue)，小李通過線上(shang)投保(bao)(bao)方式，在(zai)某保(bao)(bao)險(xian)(xian)公司(si)處為老李投保(bao)(bao)了醫療(liao)保(bao)(bao)險(xian)(xian)，投保(bao)(bao)時，小李曾填(tian)寫(xie)一份《個人健康告知書》，對(dui)(dui)所(suo)有事項均叉選“否”。2022年6月(yue)，老李因身體不適前(qian)往醫院檢查時，發(fa)現(xian)自(zi)己肺(fei)部有結節(jie)，后(hou)被確(que)(que)診罹患肺(fei)惡性(xing)腫瘤。嗣后(hou)，老李向保(bao)(bao)險(xian)(xian)公司(si)申請(qing)(qing)理賠(pei)，不料保(bao)(bao)險(xian)(xian)公司(si)認(ren)為，老李投保(bao)(bao)前(qian)曾被確(que)(que)診患有虹膜缺如，卻未在(zai)投保(bao)(bao)時如實(shi)告知，且(qie)該(gai)疾(ji)病屬于先(xian)天性(xing)疾(ji)病，對(dui)(dui)保(bao)(bao)險(xian)(xian)公司(si)承保(bao)(bao)決(jue)(jue)定會產生了重大(da)影(ying)響，拒絕賠(pei)償。索賠(pei)無果，老李訴至法院，請(qing)(qing)求判決(jue)(jue)保(bao)(bao)險(xian)(xian)公司(si)給付(fu)保(bao)(bao)險(xian)(xian)金3萬元。
法院審理(li)后認為，本案的爭議焦點在(zai)于，投(tou)保(bao)(bao)人(ren)投(tou)保(bao)(bao)時(shi)是否(fou)違反(fan)如(ru)(ru)實告(gao)知(zhi)(zhi)(zhi)義務，保(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)司(si)是否(fou)免(mian)責(ze)？首先，老李并不具(ju)有(you)專業(ye)醫學(xue)知(zhi)(zhi)(zhi)識，其不知(zhi)(zhi)(zhi)曉虹(hong)膜缺如(ru)(ru)屬(shu)于先天性(xing)疾病，也符合(he)常理(li)，保(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)司(si)在(zai)保(bao)(bao)險(xian)(xian)(xian)合(he)同里(li)未對先天性(xing)疾病作出特(te)別定義或專業(ye)解釋的情(qing)況下，讓投(tou)保(bao)(bao)人(ren)對虹(hong)膜缺如(ru)(ru)是否(fou)屬(shu)于先天性(xing)疾病進(jin)行判斷，并承擔(dan)相應后果，亦(yi)不合(he)理(li)，有(you)失公(gong)(gong)平，保(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)司(si)亦(yi)未提(ti)供投(tou)保(bao)(bao)流程(cheng)證明其盡到詢(xun)問義務，故不能認定投(tou)保(bao)(bao)人(ren)投(tou)保(bao)(bao)時(shi)，未履行如(ru)(ru)實告(gao)知(zhi)(zhi)(zhi)義務。
其次，即(ji)使投保(bao)(bao)人存(cun)在重大(da)過(guo)失，保(bao)(bao)險(xian)(xian)公(gong)司也未就(jiu)老李(li)未如實告(gao)知事(shi)(shi)項（即(ji)存(cun)在虹膜缺如）與保(bao)(bao)險(xian)(xian)事(shi)(shi)故(gu)的(de)(de)發生(sheng)（即(ji)罹患肺惡(e)性腫(zhong)瘤）之間(jian)因果關(guan)系進(jin)行舉證(zheng)，無法證(zheng)明投保(bao)(bao)人未履行該(gai)義務，對(dui)保(bao)(bao)險(xian)(xian)事(shi)(shi)故(gu)的(de)(de)發生(sheng)具有重大(da)影(ying)響。最終(zhong)法院判決支持(chi)老李(li)的(de)(de)訴請，保(bao)(bao)險(xian)(xian)公(gong)司應賠付老李(li)保(bao)(bao)險(xian)(xian)金3萬元。
近年(nian)來，居民投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)商(shang)業健(jian)康保(bao)(bao)(bao)(bao)(bao)險(xian)(xian)的(de)(de)意(yi)識逐漸增強，但“投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)容(rong)(rong)易理(li)賠(pei)難”也成為(wei)人(ren)(ren)們投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)時的(de)(de)一大困(kun)惑。保(bao)(bao)(bao)(bao)(bao)險(xian)(xian)公司拒賠(pei)的(de)(de)常見(jian)理(li)由，是認為(wei)投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)人(ren)(ren)未履行(xing)如實(shi)告(gao)知義務。因(yin)保(bao)(bao)(bao)(bao)(bao)險(xian)(xian)合同具有嚴重信(xin)息不對(dui)稱性及射幸(xing)性，而如實(shi)告(gao)知制度的(de)(de)存在(zai)(zai)(zai)有助(zhu)于(yu)平衡(heng)保(bao)(bao)(bao)(bao)(bao)險(xian)(xian)人(ren)(ren)及投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)人(ren)(ren)、被保(bao)(bao)(bao)(bao)(bao)險(xian)(xian)人(ren)(ren)等各方主體的(de)(de)利益。對(dui)于(yu)投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)人(ren)(ren)而言(yan)，在(zai)(zai)(zai)投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)時對(dui)于(yu)保(bao)(bao)(bao)(bao)(bao)險(xian)(xian)人(ren)(ren)所詢問(wen)的(de)(de)各種事項應當如實(shi)告(gao)知，否則存在(zai)(zai)(zai)拒賠(pei)風險(xian)(xian)。對(dui)于(yu)保(bao)(bao)(bao)(bao)(bao)險(xian)(xian)人(ren)(ren)而言(yan)，所詢問(wen)的(de)(de)內(nei)容(rong)(rong)應當清晰(xi)具體明確，不應籠統或模糊，讓投(tou)(tou)保(bao)(bao)(bao)(bao)(bao)人(ren)(ren)無法辨別和(he)判(pan)斷，在(zai)(zai)(zai)詢問(wen)流程及內(nei)容(rong)(rong)設計上(shang)應更為(wei)縝(zhen)密。
日期：2023-3-17 10:46:58 | 關閉 |
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