cciia.org.cn 2024-1-4 8:49:29 人(ren)民法(fa)院報
現實(shi)生活(huo)中，一些中小企業購買保(bao)(bao)險(xian)(xian)(xian)時(shi)會通過中介公(gong)(gong)(gong)司(si)向保(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)(gong)司(si)投(tou)保(bao)(bao)，這些中介公(gong)(gong)(gong)司(si)往往與(yu)保(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)(gong)司(si)建立合作，由中介公(gong)(gong)(gong)司(si)作為投(tou)保(bao)(bao)人(ren)與(yu)保(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)(gong)司(si)訂立合同。這也導致實(shi)際(ji)(ji)投(tou)保(bao)(bao)人(ren)與(yu)名義(yi)(yi)投(tou)保(bao)(bao)人(ren)不一致，這種情況(kuang)下，實(shi)際(ji)(ji)投(tou)保(bao)(bao)人(ren)申請理賠(pei)時(shi)，保(bao)(bao)險(xian)(xian)(xian)應(ying)該賠(pei)付嗎？近日，北(bei)京市東城(cheng)區(qu)人(ren)民法院審(shen)結了(le)一起保(bao)(bao)險(xian)(xian)(xian)糾紛案，認(ren)定某物資公(gong)(gong)(gong)司(si)為實(shi)際(ji)(ji)投(tou)保(bao)(bao)人(ren)，同時(shi)由于保(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)(gong)司(si)未盡到提示說明(ming)和審(shen)核義(yi)(yi)務，判(pan)決(jue)保(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)(gong)司(si)賠(pei)付。
2020年初，某中(zhong)(zhong)(zhong)(zhong)介(jie)公(gong)(gong)司(si)與某保(bao)(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)司(si)簽訂了合作(zuo)協議，由該中(zhong)(zhong)(zhong)(zhong)介(jie)公(gong)(gong)司(si)作(zuo)為投保(bao)(bao)(bao)人(ren)幫助中(zhong)(zhong)(zhong)(zhong)小(xiao)企業(ye)向保(bao)(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)司(si)投保(bao)(bao)(bao)雇主責任險(xian)(xian)(xian)。投保(bao)(bao)(bao)模式(shi)為，中(zhong)(zhong)(zhong)(zhong)介(jie)公(gong)(gong)司(si)匯總收集(ji)中(zhong)(zhong)(zhong)(zhong)小(xiao)企業(ye)相(xiang)關人(ren)員資料后交(jiao)給保(bao)(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)司(si)審核承保(bao)(bao)(bao)，保(bao)(bao)(bao)險(xian)(xian)(xian)公(gong)(gong)司(si)給中(zhong)(zhong)(zhong)(zhong)介(jie)公(gong)(gong)司(si)出具電(dian)子保(bao)(bao)(bao)單(dan)，中(zhong)(zhong)(zhong)(zhong)介(jie)公(gong)(gong)司(si)再拆分成保(bao)(bao)(bao)險(xian)(xian)(xian)承保(bao)(bao)(bao)明細發(fa)給這(zhe)些中(zhong)(zhong)(zhong)(zhong)小(xiao)企業(ye)，并(bing)收取服(fu)務(wu)費用。
2020年11月(yue)，某(mou)物資公(gong)司通過(guo)某(mou)中(zhong)(zhong)介公(gong)司在(zai)某(mou)保(bao)(bao)險(xian)公(gong)司投(tou)保(bao)(bao)了雇(gu)主(zhu)責任(ren)險(xian)。保(bao)(bao)險(xian)公(gong)司出(chu)具的保(bao)(bao)單(dan)載(zai)明，投(tou)保(bao)(bao)人及被(bei)保(bao)(bao)險(xian)人為某(mou)中(zhong)(zhong)介公(gong)司，物資公(gong)司員工王某(mou)在(zai)保(bao)(bao)單(dan)的雇(gu)員清單(dan)之列，工種(zhong)為車床工，職業(ye)類(lei)別(bie)為四類(lei)。
2020年11月20日，處在保險(xian)期內的王某在車間操作切割(ge)機器時(shi)，不慎碰(peng)到左(zuo)手(shou)，導(dao)致左(zuo)手(shou)受(shou)傷，手(shou)指被(bei)切斷(duan)。物資公司將(jiang)王某送醫治(zhi)療并支付(fu)了治(zhi)療費用。
物資公(gong)(gong)(gong)司(si)(si)(si)(si)遂找中介公(gong)(gong)(gong)司(si)(si)(si)(si)及保(bao)險(xian)(xian)公(gong)(gong)(gong)司(si)(si)(si)(si)，申請保(bao)險(xian)(xian)理賠(pei)。2021年(nian)6月9日，保(bao)險(xian)(xian)公(gong)(gong)(gong)司(si)(si)(si)(si)出(chu)具(ju)拒賠(pei)通(tong)知書，認(ren)為(wei)(wei)王(wang)某投(tou)保(bao)的職業類(lei)(lei)別為(wei)(wei)四(si)類(lei)(lei)，但出(chu)險(xian)(xian)時從事的車床切割(ge)工作為(wei)(wei)五類(lei)(lei)職業，根據保(bao)單(dan)第八(ba)條“出(chu)險(xian)(xian)時，若被保(bao)險(xian)(xian)人雇員(yuan)實(shi)際職業類(lei)(lei)別高于(yu)保(bao)單(dan)人員(yuan)清單(dan)列明職業類(lei)(lei)別的，不(bu)承擔保(bao)險(xian)(xian)責任(ren)”，不(bu)承擔賠(pei)償(chang)。物資公(gong)(gong)(gong)司(si)(si)(si)(si)與保(bao)險(xian)(xian)公(gong)(gong)(gong)司(si)(si)(si)(si)多次溝通(tong)未(wei)果(guo)，起訴至東(dong)城區法(fa)院，要求保(bao)險(xian)(xian)公(gong)(gong)(gong)司(si)(si)(si)(si)賠(pei)償(chang)保(bao)險(xian)(xian)金。案件受理后，法(fa)院依法(fa)追加中介公(gong)(gong)(gong)司(si)(si)(si)(si)作為(wei)(wei)第三人出(chu)庭應(ying)訴。
庭審中，原告物資公(gong)司(si)稱(cheng)，是(shi)業務員上門(men)推銷保(bao)險的(de)，工(gong)人就在現場干(gan)活，業務員讓怎么投(tou)保(bao)原告就怎么投(tou)，不懂四類五類工(gong)種區別，員工(gong)王某從(cong)事的(de)是(shi)車床(chuang)工(gong)，投(tou)保(bao)的(de)也是(shi)車床(chuang)工(gong)，不存(cun)在故意隱(yin)瞞。關于(yu)免(mian)責(ze)條款(kuan)的(de)事情沒有人說過，原告堅持(chi)認為保(bao)險公(gong)司(si)應當理賠。
被告保險(xian)公(gong)司(si)(si)認為，保單(dan)是中(zhong)介公(gong)司(si)(si)與其簽訂，投(tou)保人(ren)系(xi)中(zhong)介公(gong)司(si)(si)，原告并非投(tou)保人(ren)，不具備投(tou)保人(ren)資格(ge)，無權提(ti)起訴訟(song)。同時，保險(xian)公(gong)司(si)(si)與中(zhong)介公(gong)司(si)(si)之間簽訂有框(kuang)架(jia)協議和確認函(han)，明確了工種(zhong)類(lei)別及低(di)于實際類(lei)別投(tou)保免賠的內(nei)容，以低(di)保費(fei)投(tou)保高風險(xian)的工種(zhong)應(ying)適用保險(xian)的免責(ze)條款(kuan)，不應(ying)賠付。
第(di)三人(ren)(ren)中介公(gong)(gong)司表示，與保(bao)(bao)險公(gong)(gong)司之間有合作(zuo)協議，其作(zuo)為投保(bao)(bao)人(ren)(ren)為一些中小企業投保(bao)(bao)，實際的(de)被保(bao)(bao)險人(ren)(ren)是(shi)這些企業和(he)中介公(gong)(gong)司。原告的(de)員工(gong)王某(mou)投保(bao)(bao)、出險、理賠(pei)申請等都(dou)是(shi)事實，保(bao)(bao)險公(gong)(gong)司應當(dang)進行(xing)賠(pei)付。
法院審理后認為，關于某(mou)(mou)物資公(gong)司是(shi)否具有投(tou)(tou)(tou)保(bao)(bao)人(ren)資格(ge)，從(cong)當事人(ren)陳(chen)述的(de)投(tou)(tou)(tou)保(bao)(bao)模式來看，中介公(gong)司雖然是(shi)保(bao)(bao)險(xian)(xian)單上(shang)列(lie)明的(de)投(tou)(tou)(tou)保(bao)(bao)人(ren)，但該(gai)投(tou)(tou)(tou)保(bao)(bao)人(ren)角色更多(duo)是(shi)名義上(shang)的(de)，實際(ji)上(shang)的(de)投(tou)(tou)(tou)保(bao)(bao)人(ren)及(ji)被保(bao)(bao)險(xian)(xian)人(ren)應當是(shi)某(mou)(mou)物資公(gong)司這些客觀(guan)上(shang)有保(bao)(bao)險(xian)(xian)需求、具有保(bao)(bao)險(xian)(xian)利(li)益、實際(ji)支(zhi)付保(bao)(bao)費(fei)的(de)雇主。如果僅根據保(bao)(bao)單上(shang)載明的(de)投(tou)(tou)(tou)保(bao)(bao)人(ren)認定(ding)某(mou)(mou)物資公(gong)司無(wu)權提起訴(su)訟，對實際(ji)支(zhi)付保(bao)(bao)費(fei)的(de)某(mou)(mou)物資公(gong)司有失公(gong)平。
根(gen)據《中(zhong)(zhong)華(hua)人(ren)民共和(he)國保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)法(fa)》第(di)十七條(tiao)(tiao)第(di)二款(kuan)的(de)(de)(de)規定，對(dui)保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)合同(tong)中(zhong)(zhong)免除保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)人(ren)責(ze)任的(de)(de)(de)條(tiao)(tiao)款(kuan)，保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)人(ren)在訂(ding)立合同(tong)時應當在投(tou)(tou)(tou)保(bao)(bao)(bao)(bao)單(dan)、保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)單(dan)或(huo)(huo)者其他保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)憑(ping)證上作出(chu)足以(yi)引起投(tou)(tou)(tou)保(bao)(bao)(bao)(bao)人(ren)注意的(de)(de)(de)提(ti)示，并對(dui)該條(tiao)(tiao)款(kuan)的(de)(de)(de)內容(rong)以(yi)書面或(huo)(huo)者口頭形(xing)式向投(tou)(tou)(tou)保(bao)(bao)(bao)(bao)人(ren)作出(chu)明確(que)(que)說明；未(wei)作提(ti)示或(huo)(huo)者明確(que)(que)說明的(de)(de)(de)，該條(tiao)(tiao)款(kuan)不產生效力。本案中(zhong)(zhong)，保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司(si)提(ti)交的(de)(de)(de)電子保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)單(dan)中(zhong)(zhong)對(dui)特別約定內容(rong)包括保(bao)(bao)(bao)(bao)單(dan)第(di)八(ba)條(tiao)(tiao)，并未(wei)予以(yi)加黑、加粗等(deng)方式進(jin)行提(ti)醒。保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司(si)雖然提(ti)交了經(jing)中(zhong)(zhong)介(jie)公(gong)司(si)蓋章確(que)(que)認的(de)(de)(de)確(que)(que)認函，明確(que)(que)所有涉及操(cao)作切割機器的(de)(de)(de)操(cao)作工人(ren)需按(an)照(zhao)五類(lei)人(ren)員(yuan)(yuan)進(jin)行投(tou)(tou)(tou)保(bao)(bao)(bao)(bao)，但(dan)僅(jin)從(cong)確(que)(que)認函無法(fa)認定雙方協商一(yi)致，王(wang)某應當按(an)照(zhao)五類(lei)人(ren)員(yuan)(yuan)標準(zhun)投(tou)(tou)(tou)保(bao)(bao)(bao)(bao)。此外，在中(zhong)(zhong)介(jie)公(gong)司(si)投(tou)(tou)(tou)保(bao)(bao)(bao)(bao)時明確(que)(que)王(wang)某為(wei)車(che)(che)床工、投(tou)(tou)(tou)保(bao)(bao)(bao)(bao)類(lei)別為(wei)四類(lei)的(de)(de)(de)情(qing)況下，保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司(si)在核保(bao)(bao)(bao)(bao)時并未(wei)進(jin)一(yi)步核實，也(ye)未(wei)對(dui)車(che)(che)床工按(an)四類(lei)人(ren)員(yuan)(yuan)投(tou)(tou)(tou)保(bao)(bao)(bao)(bao)提(ti)出(chu)異(yi)議。從(cong)在案證據及當事人(ren)陳述的(de)(de)(de)投(tou)(tou)(tou)保(bao)(bao)(bao)(bao)情(qing)況來看(kan)，都不足以(yi)證明保(bao)(bao)(bao)(bao)險(xian)(xian)(xian)(xian)公(gong)司(si)盡(jin)到了充分(fen)審(shen)慎的(de)(de)(de)提(ti)示說明義(yi)務(wu)和(he)審(shen)核義(yi)務(wu)。
最終，法(fa)院認為(wei)保(bao)險(xian)公司(si)免(mian)賠的(de)依據不足，判(pan)決被告保(bao)險(xian)公司(si)向原(yuan)告物資(zi)公司(si)支付保(bao)險(xian)賠償金18737元。保(bao)險(xian)公司(si)不服一審判(pan)決，提起上訴。二審駁回(hui)上訴，維(wei)持原(yuan)判(pan)。
■法官說法■
本案承(cheng)辦法(fa)(fa)官介紹，保(bao)險(xian)(xian)(xian)公司作為(wei)專(zhuan)業(ye)從(cong)事保(bao)險(xian)(xian)(xian)業(ye)務的(de)機構，對保(bao)險(xian)(xian)(xian)業(ye)務具(ju)有天然的(de)專(zhuan)業(ye)性，而普通(tong)大眾往(wang)往(wang)缺乏專(zhuan)業(ye)的(de)保(bao)險(xian)(xian)(xian)知識，對保(bao)險(xian)(xian)(xian)的(de)認知有限，考慮到雙方的(de)差異，在(zai)法(fa)(fa)律上(shang)應做好利益平衡，保(bao)險(xian)(xian)(xian)法(fa)(fa)也(ye)從(cong)總體(ti)(ti)上(shang)對保(bao)險(xian)(xian)(xian)公司的(de)義(yi)務有更(geng)多的(de)規定。因而，在(zai)名(ming)義(yi)投(tou)保(bao)人與實際投(tou)保(bao)人不一致時(shi)，不能(neng)僅依據保(bao)單(dan)進行(xing)認定，要透過現象看(kan)本質，具(ju)體(ti)(ti)情況應具(ju)體(ti)(ti)分(fen)析，通(tong)過投(tou)保(bao)模式、投(tou)保(bao)過程等(deng)綜合(he)認定。
對(dui)于保(bao)險公司等專業保(bao)險機構(gou)，在承保(bao)時應盡到對(dui)相關材(cai)(cai)(cai)料(liao)(liao)的嚴(yan)格審核(he)義務。如果投保(bao)人按保(bao)險合同約定(ding)提(ti)(ti)交(jiao)(jiao)(jiao)了相關證(zheng)明(ming)材(cai)(cai)(cai)料(liao)(liao)，此時保(bao)險公司應當對(dui)投保(bao)人提(ti)(ti)交(jiao)(jiao)(jiao)的材(cai)(cai)(cai)料(liao)(liao)進行審核(he)，決(jue)定(ding)是否承保(bao)，切不可為促成交(jiao)(jiao)(jiao)易達成而不認真審核(he)材(cai)(cai)(cai)料(liao)(liao)甚至不進行實質審核(he)。
對于(yu)免責條款，保(bao)(bao)(bao)險公(gong)(gong)司作為條款的(de)制(zhi)定人自(zi)然應對投保(bao)(bao)(bao)人進(jin)行提(ti)(ti)示說(shuo)明(ming)(ming)，否則(ze)該(gai)條款不產生效力。如(ru)何提(ti)(ti)示說(shuo)明(ming)(ming)？保(bao)(bao)(bao)險公(gong)(gong)司既可以(yi)(yi)(yi)(yi)通過(guo)在保(bao)(bao)(bao)險憑證(zheng)上(shang)以(yi)(yi)(yi)(yi)加(jia)粗、加(jia)黑(hei)、設置下劃(hua)線等足以(yi)(yi)(yi)(yi)引起(qi)投保(bao)(bao)(bao)人注意的(de)方式(shi)進(jin)行書(shu)面提(ti)(ti)示，也可以(yi)(yi)(yi)(yi)在訂立條款時通過(guo)保(bao)(bao)(bao)險專員進(jin)行視頻、現場等方式(shi)口頭提(ti)(ti)示和(he)說(shuo)明(ming)(ming)。但(dan)無論(lun)采取何種(zhong)方式(shi)，保(bao)(bao)(bao)險公(gong)(gong)司都應舉證(zheng)證(zheng)明(ming)(ming)自(zi)己已經履(lv)行提(ti)(ti)示說(shuo)明(ming)(ming)義務，否則(ze)視為未作提(ti)(ti)示或說(shuo)明(ming)(ming)。
此外，投(tou)(tou)保(bao)(bao)(bao)人在投(tou)(tou)保(bao)(bao)(bao)時(shi)要秉持誠信原則，告知保(bao)(bao)(bao)險(xian)(xian)人自身(shen)情況并(bing)提(ti)供材(cai)料，如實進行投(tou)(tou)保(bao)(bao)(bao)。一旦隱瞞重要信息而投(tou)(tou)保(bao)(bao)(bao)成功，可能導致出險(xian)(xian)時(shi)無(wu)法(fa)賠付，將(jiang)自身(shen)置于不利地位。投(tou)(tou)保(bao)(bao)(bao)人在投(tou)(tou)保(bao)(bao)(bao)時(shi)應多了解保(bao)(bao)(bao)險(xian)(xian)知識(shi)，選擇合適的(de)保(bao)(bao)(bao)險(xian)(xian)投(tou)(tou)保(bao)(bao)(bao)，最大限(xian)度(du)維護(hu)自身(shen)合法(fa)權益。
日期：2024-1-4 8:49:29 | 關閉 |
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