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Li Sijia v. Xiling Life Insurance Company (Case of Dispute over Contract of Personal Insurance)
李思佳诉西陵人保公司人身保险合同纠纷案
【法宝引证码】

Li Sijia v. Xiling Life Insurance Company (Case of Dispute over Contract of Personal Insurance)
(Case of Dispute over Contract of Personal Insurance)
李思佳诉西陵人保公司人身保险合同纠纷案

Li Sijia v. Xiling Life Insurance Company
(Case of Dispute over Contract of Personal Insurance)@#
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BASIC FACTS@#
Plaintiff: Li Sijia, female, 11 years old, student, resides at Yiling Road, Yichang, Hubei Province.@#
Legal Representative: Li Bin (Li Sijia's father), male, 38 years old, a cadre of the industrial and commercial bureau of Yichang City, resides at the same place as Li Sijia.@#
Defendant: Yichang Xiling Branch of China Life Insurance Co., Ltd., located at No.1 Road, Xiling, Yichang.@#
Representative: Gao Ping, manager of the branch company.@#
PROCEDURAL POSTURE@#
The plaintiff Li Sijia brought a suit to People's Court of Xiling District, Yichang, Hubei Province with her father Li Bin as legal representative for the dispute over insurance contract with the defendant Yichang Xiling Branch of China Life Insurance Co., Ltd. (hereinafter referred to as Xiling Branch).@#
Li Sijia alleged that: in May 2003, her mother bought a student safety insurance (with additional accidental medical insurance of accidental injury) for her at the defendant Xiling Branch, but Xiling Branch did not produce written insurance contract according to the relevant provisions. She bought additional insurance of the same type at Yichang Center Branch of Taikang Life Insurance Co., Ltd. (hereinafter referred to as Taikang Insurance Company). On January 7th, 2004, she was injured in a traffic accident, which cost her medical expenses of 1313.90 yuan. In March 2004, she had the claim settled at Taikang Insurance Company with the original invoices of her medical expenses. Later she went to the defendant to request for settling the claim with the photocopies of the invoices of medical expenses and the original case history, but till now, the defendant refused to settle the claim under the pretext that the claim settlement procedure may only be transacted with the original invoices of medical expenses. Thus the plaintiff pleads with the court to adjudicate the defendant pay the plaintiff the medical insurance money of 1313.90 yuan.@#
The evidences provided by the plaintiff are as follows:@#
1. A copy of the industrial and commercial registration information of the defendant, which proves that the defendant is entitled to run accidental injury medical insurance business;@#
2. Invoice of insurance premium, list of payments for buying insurance by Vocational Education Center of Yichang City and the corresponding certificates, which prove that there existed an insurance contract relationship between the plaintiff and the defendant and the fact that the defendant did not produce written insurance contract to the plaintiff;@#
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李思佳诉西陵人保公司人身保险合同纠纷案@#
【裁判摘要】@#
一、根据保险法九十二条第二款规定,意外伤害保险属于人身保险,不适用财产保险中的“损失补偿原则”。@#
二、保险合同中有保险人责任免除条款的,在订立保险合同时,保险人应当向投保人明确说明;未明确说明的,该条款不产生效力,保险公司应当按照合同约定理赔。@#
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原告:李思佳,女,11岁,学生,住湖北省宜昌市夷陵路。@#
法定代理人:李斌(系李思佳之父),男,38岁,宜昌市工商局干部,住址同上。@#
被告:中国人寿保险股份有限公司宜昌西陵区支公司,住所地:宜昌市西陵一路。@#
代表人:高萍,该支公司经理。@#
@#
原告李思佳因与被告中国人寿保险股份有限公司宜昌西陵区支公司(以下简称西陵人保公司)发生保险合同纠纷,由其父李斌作为法定代理人,向湖北省宜昌市西陵区人民法院提起诉讼。@#
原告李思佳诉称:2003年5月,原告之母在被告西陵人保公司为原告购买学生平安保险一份(该保险附加意外伤害医疗保险),被告未按规定出具书面保险合同。原告在泰康人寿保险股份有限公司宜昌中心支公司(以下简称泰康保险公司)购买了相同类型的附加保险。2004年1月7日,原告因发生交通事故受伤,共花去医疗费 1313.90元。2004年3月,原告持医疗费发票原件到泰康保险公司进行了理赔。后原告持医疗费发票复印件及病历原件到被告处要求理赔,被告却以必须持医疗费发票原件方可办理理赔手续为由至今不予理赔。请求判令被告向原告支付医疗保险金 1313.90元。@#
原告提供以下证据:@#
1.被告单位工商登记资料一份,用以证明被告有权经营意外伤害保险业务;@#
2.保险费发票、宜昌市职业教育中心投保缴费清单及证明,用以证明原、被告之间存在保险合同关系及被告未向原告出具书面保险合同的事实;@#
3.宜昌市公安局交警支队事故处理大队道路交通事故责任认定书及损害赔偿调解书,用以证明原告2004年1月7日乘坐摩托车发生交通事故并受伤;@#
4.宜昌市第一人民医院病历及医疗费收据,用以证明原告因交通事故受伤后就医,共支付医疗费1313.90元;@#
5.原告与泰康保险公司的保险合同条款及医疗保险金给付分割单和批单,用以证明泰康保险公司对原告的医疗费损失,除保险合同约定的50元免赔额外,已全部赔付。@#
被告西陵人保公司辩称:原告李思佳在我公司投保的学生平安保险中附加的意外伤害医疗保险,是一种财产性质的保险,应适用损失补偿原则理赔,原告在已经获得泰康保险公司赔付的情况下,不能重复理赔。我公司要求原告提供医疗费原始凭证,是为了确认原告的损失是否获得赔偿,并对重复理赔行为加以控制。原告因交通事故受伤而支付的医疗费已经获得赔偿,我公司有权拒绝赔付。故原告的诉讼请求应当依法驳回。@#
被告提供中国人寿保险股份有限公司《国寿学生、幼儿平安保险附加意外伤害医疗保险条款》,用以证明原告发生的事故属于合同条款中所称的“意外伤害事故”。根据该条款,原告要求理赔,需提供医疗费等相关资料原件。@#
在庭审质证中,双方当事人对上述证据的合法性、真实性均无异议,宜昌市西陵区人民法院对双方提供的证据均予确认。@#
宜昌市西陵区人民法院经审理查明:@#
2003年5月7日,原告李思佳之母所在单位宜昌市职业教育中心在被告西陵人保公司为原告购买“学生、幼儿平安保险”一份(该保险附加意外伤害医疗保险,保险期间为1年),并按规定交纳了保险费。 2004年1月7日,原告乘坐李某驾驶的鄂 EA9821号二轮摩托车在本市城区发生交通事故,致使原告受伤,经宜昌市第一人民医院门诊治疗,用去医疗费1313.90元。因原告另在泰康保险公司购买四季长乐终生分红人身保险,该保险亦附加意外伤害医疗保险,事故发生后,原告持医疗费发票原件等相关资料到泰康保险公司要求理赔,该公司依保险合同为原告赔付医疗保险金 1263.90元(实际支付的医疗费1313.90元减去免赔额50元)。之后,原告持医疗费发票复印件等相关资料到被告处要求理赔,被告拒绝赔付。@#
宜昌市西陵区人民法院认为:@#
本案争议的焦点是:1.意外伤害医疗保险是人身保险还是财产保险。2.原告要求理赔,是否必须提供医疗费单据等资料原件。@#
关于第一点。《中华人民共和国保险法》(以下简称保险法)中所称保险,包括财产保险和人身保险两大类。人身保险是以人的寿命和身体为保险标的的保险。原告在被告处投保的“学生、幼儿平安保险”,是对被保险人因疾病或遭受意外伤害造成死亡或身体残疾,由保险人按约定给付保险金的保险,属于人身保险;其附加的意外伤害医疗保险,是以被保险人身体因遭受意外伤害需要治疗为给付保险金条件的保险,其性质亦应属人身保险。因此,被告应按照保险法中关于人身保险合同的赔付原则支付保险金。被告关于附加的意外伤害医疗保险是一种财产性质的保险,应适用损失补偿原则理赔的答辩观点无法律依据,不予采纳。@#
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