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Feng Yueshun v. Sun Life Everbright Life Insurance Co., Ltd.
冯跃顺诉光大永明人寿保险有限公司保险合同纠纷案
【法宝引证码】

Feng Yueshun v. Sun Life Everbright Life Insurance Co., Ltd.

 

冯跃顺诉光大永明人寿保险有限公司保险合同纠纷案

(Case of Dispute over Insurance Contract) 【裁判摘要】

[Judgment Abstract]

 根据保险法九十二条第二款的规定,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”。被保险人或者受益人从实施致害行为的第三者处获得侵权赔偿后,仍然可以向保险人主张保险理赔,保险人不得以被保险人或者受益人已经获得侵权赔偿为由拒绝履行保险理赔责任。
Under Paragraph 2, Article 92 of the Insurance Law,accidental injury insurance belongs to personal insurance, and shall not applythe “compensationfor loss”principle under property insurance. Where aninsuredor beneficiary obtained tort damages froma third partyinjurer, he or she can stillclaim against the insurer for compensation under the insurance contract, andthe insurer shall not refuse to pay theinsurance claimson the ground that the insured or the beneficiary has obtained the tort damages. 
BASIC FACTS 原告:冯跃顺,男,37岁,天津市网通公司职员,住天津市河西区竹林路秀峰里。

Plaintiff: Feng Yueshun, male, 37-year-old, employee of Tianjin Netcom Company, resides at Xiufengli, Zhulin Road of Hexi District, Tianjin Municipality.

 被告:光大永明人寿保险有限公司,住所地:天津市和平区南京路75号国际大厦。
Defendant: Sun Life Everbright Life Insurance Co., Ltd., located at International Building, No. 75 of Nanjing Road of Heping District, Tianjin Municipality. 原告冯跃顺因与被告光大永明人寿保险有限公司(以下简称光大永明)发生保险合同纠纷,向天津市和平区人民法院提起诉讼。
For the dispute over insurance contract with Sun Life Everbright Life Insurance Co., Ltd. (hereinafter referred to as Sun Life), Feng Yueshun filed a lawsuit with Heping District People's Court of Tianjin Municipality. 原告冯跃顺诉称:2005年1月25日,原告与被告光大永明签订个人意外伤害保险合同。2005年6月,原告因交通事故受到意外伤害,经住院治疗,花费各项治疗费用共计7200元。原告就此向被告申请保险理赔,被告以原告没有提交交通事故调解书及相关原始发票,且原告已接受交通事故肇事司机赔偿为由,拒绝赔偿原告保险金。原告认为,根据公安交通管理部门的规定,交通事故调解书并不发放给原告,原告无法提供;被告以原告提交相关原始发票等单据的原件作为保险理赔的前提条件没有法律依据,原告已经向被告充分证明了涉案交通事故的相关事实,且原告最初曾持全部原始单据向被告理赔,但被告提出“应先由肇事司机赔偿后再进行保险理赔”。而原告从肇事司机处获得赔偿后,被告又以此为由拒赔,显然缺乏诚信。原告与被告之间订立的个人意外伤害保险合同中并没有载明“被保险人由于第三者伤害,依法应由第三者承担赔偿责任时,保险人免责”的内容,故被告应当依照保险合同进行保险理赔。被告此举违反了《中华人民共和国保险法》(以下简称保险法)第六十八条的规定,请求依法判令被告赔偿原告医疗费5000元。
Feng Yueshun claimed that: on January 25th, 2005, Feng concluded an individual accidental injury insurance contract with Sun Life. In June 2005, he was injured in a traffic accident, and the expenses on medical treatment totaled 7200 yuan. The plaintiff thus made an insurance claim against the defendant, which refused to pay the insurance money on the ground that the plaintiff failed to provide the traffic accident mediation paper and the relevant original invoices and that the plaintiff had accepted the compensation made by the driver causing the traffic accident. The plaintiff believed that: he could not provide the mediation paper because it was not issued to the plaintiff pursuant to the rules of the public security and traffic control departments; it lacked legal basis for the defendant to take the plaintiff's provision of the related original voices and other papers as the precondition for settling the insurance claim; the plaintiff has sufficiently proved the related facts in the traffic accident, in addition, the plaintiff has provided all original documents to the defendant when he firstly made the insurance claim, yet the defendant said that “the insurance claim will be settled after the driver causing the accident makes compensation,” but after the driver causing the accident made compensation, the defendant still refused to settle, obviously, the defendant had no good faith; the individual accidental injury insurance contract concluded between the two parties did not say that ”if the insurant gets injured as a result of the act of a third party and the third party shall assume the liability for compensation pursuant to law, the insurer shall be exempted from liability,” so the defendant shall settle the insurance claim in accordance with the insurance contract. The defendant's refusal to make compensation has violated the provision of Article 68 of the Insurance Law of the People's Republic of China (hereinafter referred to as Insurance Law), therefore, the plaintiff pleas the court to order the defendant to pay 5000 yuan for the plaintiff's medical expenses. 原告冯跃顺提交了涉案个人意外伤害保险合同、证人证言材料、被告光大永明于 2005年11月7日向原告出具的保险理赔通知书、涉案交通事故损害赔偿调解书、交通事故损害赔偿相关材料等证据,用以证明其诉讼主张。
...... 被告光大永明辩称:原告冯跃顺未依照涉案个人意外伤害保险合同的约定向被告提供办理保险理赔的相关原始单据材料,被告无法做出保险理赔决定;被告对原告的医疗费用已经做出保险理赔,原告也已经获得交通事故肇事司机的赔偿,原告因涉案交通事故发生的损失已经得到必要、充分的填补,不应就涉案交通事故损害赔偿义务人已经给予赔偿的损失再次要求被告进行保险理赔,否则将违背损失补偿原则。请求判令驳回原告的诉讼请求。
 被告光大永明为证明其诉讼主张,提交了原告冯跃顺的投保书、涉案个人意外伤害保险合同、原告于2005年8月1日向被告提交的保险理赔给付申请书、天津市公安交通管理局河西支队于2005年7月 13日出具的公交西(2005)第384号《交通事故认定书》、原告于2005年9月14日就保险理赔资料事项出具的声明、被告于 2005年9月26日向原告出具的保险理赔通知书、被告于2005年10月24日向原告出具的保险理赔批单等证据。
 天津市和平区人民法院一审查明:
 2005年1月20日,原告冯跃顺向被告光大永明提交投保书,申请投保光大永明“永宁康顺综合个人意外伤害保险(精英计划)”,并预交了保险费388元。光大永明于2005年1月27日向冯跃顺出具保单,确定:光大永明承保冯跃顺投保的“永宁康顺综合个人意外伤害保险(精英计划)”,保险期间自2005年1月26日至2006年1月25日,意外伤害医疗保险金为5000元,每日住院给付金额为每天20元。该保险合同第十五条第七项第一款规定:“被保险人因遭受本合同认定的意外事故,需经医院进行必要的治疗,本公司对其自事故发生之日起180日内支出的必须且合理的实际医疗费用100元以上部分向被保险人给付意外伤害医疗保险金。被保险人意外伤害医疗保险金的累计给付以保险单载明的意外伤害医疗保险金金额为限。”
 ......

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