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Case of Yao Hongwei v. Anyang Branch of the China Continent Insurance et.al by Neihuang County People's Court of Henan Province (dispute over contract of personal insurance)
(dispute over contract of personal insurance)
河南内黄法院判决晁红伟诉大地财险安阳支公司等人身保险合同案
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[Key Terms]
insurance contract ; original ; refusal to pay indemnities
[核心术语]
保险合同;原件;拒赔
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[Disputed Issues]
Where the insured does not provide the original document of medical fee, can the insurance company refuse to pay indemnities?
[争议焦点]
被保险人未提供医疗费单据原件，保险公司能否以此拒赔？
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[Case Summary]
Under Article 22 of the Insurance Law after an insured incident occurs the insurance applicant insurant or beneficiary claiming indemnity or insurance money against the insurer under the insurance contract shall provide the insurer with available certificates and materials related to the determination of the nature cause...
[案例要旨]
我国《保险法》第二十二条规定保险事故发生后依照保险合同请求保险人赔偿或给付保险金时...
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Full-text omitted. | | 河南内黄法院判决晁红伟诉大地财险安阳支公司等人身保险合同案 |
| | ——未提供医保报销原件不能成为保险公司拒赔理由 |
| | 裁判要旨 |
| | 加盖医保中心印章的社保医疗费用复印件，足以认定相关费用及事件的真实性，被保险人可以依据这些医疗单据向保险公司要求理赔；保险公司也不能以被保险人享受了社会保险中的权利为由而不履行其在商业保险中的义务。 |
| | 案情 |
| | 2011年12月29日，晁红伟经被告中国大地财产保险股份有限公司安阳中心支公司（以下简称大地财险安阳支公司）内黄营销部职工季某的介绍购买了该公司自助式保险卡1张，经电脑激活后投保了意外伤害医疗保险1份，标准保费为50元，保险金额为每年3000元。2012年2月14日，原告晁红伟因意外扭伤脚踝住院治疗，并于当日向内黄营销部备案，填写人身保险报案登记表一份。2012年2月15日，内黄营销部出具了人身险理赔案件调查报告，并认定“摔伤事故真实，属于保险责任。”2012年3月6日，晁红伟出院，共住院18天，医疗费25244.60元。2012年3月7日，晁红伟作为城镇职工拿着原始医疗单据到内黄县医疗保险中心报销医疗费用，医疗保险中心统筹支付给晁红伟现金19461.44元。随后，晁红伟拿着加盖医保中心印章的医疗费用复印单到内黄县营销部，要求其支付保险金，内黄营销部以原告未提供原始医疗费单据为由拒付保险金。晁红伟认为，虽然当时没提供保险原始单据，但已经被告工作人员核实属于保险责任范围，被告未作出理赔有违诚信原则，故诉至河南省内黄县法院，要求被告理赔。被告大地财险安阳支公司及内黄营销部辩称：没有理赔是因为原告未按规定提供医疗费用原始单据，且原告已从其他部门获得报销，不能重复获得理赔。 |
| | 裁判 |
| | 河南省内黄县人民法院经审理认为，原告晁红伟在被告内黄营销部购买自助式保险卡1张，经电脑激活后投保了该公司的意外伤害医疗保险1份，事实清楚，证据确实充分。原告发生意外事故后，经保险公司调查属于保险责任，理应及时赔偿，却因迟迟不予理赔，以致酿成本案纠纷，被告应负全部责任，故对原告要求被告给付保险金3000元之诉请予以支持。被告大地财险安阳支公司以“原告未提供医疗费用原始单据，且已从医疗保险处获得赔偿，不能重复理赔”的辩解不能成立。理由是原告提供了在社会医疗保险机构报销过的票据复印件，且已加盖有社会医疗保险中心的印章，足以证明该费用的真实性。且原告和被告之间的合同系人身保险合同，由于人的生命和健康是难以用价值来衡量的，所以人身险可以多份投保、重复投保，也允许投保人得到多份保险金，多重赔偿，这种合同不适用于补偿原则。被告内黄营销部属大地财险安阳支公司的分支机构，不具备独立承担民事责任的能力，其责任应由大地财险安阳支公司承担。 |
| | ．．．．．． |
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