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Wang Yuguo v. Huai'an City Chuzhou Branch of China Life Insurance Co., Ltd. (Case concerning Insurance Contract Disputes)
王玉国诉中国人寿保险公司淮安市楚州支公司保险合同纠纷案
【法宝引证码】

Wang Yuguo v. Huai'an City Chuzhou Branch of China Life Insurance Co., Ltd. (Case concerning Insurance Contract Disputes)
(Case concerning Insurance Contract Disputes)
王玉国诉中国人寿保险公司淮安市楚州支公司保险合同纠纷案
Wang Yuguo v. Huai'an City Chuzhou Branch of China Life Insurance Co., Ltd. (Case concerning Insurance Contract Disputes) 王玉国诉中国人寿保险公司淮安市楚州支公司保险合同纠纷案
[Judgment Abstract] [裁判摘要]
Where an insurance company prescribes a limit to the treatment method of the disease the insured suffers from with the standard terms of an insurance contract, it does not conform to the medical treatment rule and violates the purpose of concluding the insurance contract. The insured has the right to choose the optimal treatment method according to his own conditions and he should unnecessarily be subject to restrictions on the treatment method in the insurance contract. The insurance company shall not exempt its own insurance liability on the ground that the insured does not choose the treatment method as designated in the insurance contract. 保险公司以保险合同格式条款限定被保险人患病时的治疗方式,既不符合医疗规律,也违背保险合同签订的目的。被保险人有权根据自身病情选择最佳的治疗方式,而不必受保险合同关于治疗方式的限制。保险公司不能以被保险人没有选择保险合同指定的治疗方式而免除自己的保险责任。
Plaintiff: Wang Yuguo, male, 52 years old, Chinese Han, domiciled in Huai'an City, Jiangsu Province. 原告:王玉国。
Defendant: Huai'an City Chuzhou Branch of China Life Insurance Co., Ltd., domiciled in Zhenhuailou East Road, Huai'an District, Huai'an City, Jiangsu Province. 被告:中国人寿保险股份有限公司淮安市楚州支公司。
Person-in-Charge: Li Xuebiao, Manager of the Company. 负责人:李学标,该公司经理。
Plaintiff Wang Yuguo filed a lawsuit with the People's Court of Huai'an District, Huai'an City, Jiangsu Province against defendant Huai'an City Chuzhou Branch of China Life Insurance Co., Ltd. (hereinafter referred to as “Chuzhou Branch of China Life Insurance”) for insurance contract disputes. 原告王玉国因与被告中国人寿保险股份有限公司淮安市楚州支公司(以下简称人寿保险楚州支公司)发生保险合同纠纷,向江苏省淮安市淮安区人民法院提起诉讼。

Plaintiff Wang Yuguo alleged that: On July 30, 2009, plaintiff and defendant concluded a Kangning WholeLife Insurance Contract. Paragraph 1 of Clause 5 of the Contract stipulates that after 180 days from the effective date of the Contract, if the insured suffers from a critical illness as mentioned in the Contract for the first time, Chuzhou Branch of China Life Insurance shall pay the insured the critical disease insurance premiums, which are two times the basic insurance amount. The insurance amount in the Contract was 20,000 yuan. On February 12, 2011, plaintiff was diagnosed as suffering from aortic dissection by the First People's Hospital of Huai'an City, which suggested that plaintiff should be transferred to a superior hospital for further treatment. On February 22, 2011, plaintiff received a surgical treatment in the People's Hospital of Jiangsu Province, with the total medical expenses of more than 100,000 yuan. Plaintiff repeatedly claimed settlement to defendant, but defendant refused to pay him the insurance premiums. Therefore, he requested the court to legally order that defendant should pay plaintiff the insurance premiums of 40,000 yuan and it should bear the litigation fees and appraisal fees.

 

原告王玉国诉称:2009年7月30日,原、被告签订了康宁终身保险合同一份,合同第五条第一款约定:被保险人于合同生效之日起180日后,初次发生本合同所指的重大疾病,人寿保险楚州支公司按基本保险金额的二倍给付重大疾病保险。合同保险金额2万元。2011年2月12日,原告经淮安市第一人民医院确诊为主动脉夹层并建议转上级医院继续治疗,2011年2月 22日,原告在江苏省人民医院手术治疗,共用去医疗费用10多万元。原告多次要求被告理赔,但被告拒不给付保险金。请求法院依法判令被告给付原告保险金4万元,并由被告承担诉讼费、鉴定费。

...... 被告人寿保险楚州支公司辩称:原告王玉国于2009年7月30日与被告签订康宁终身保险合同(2007版)是事实,因原告所患疾病(手术)不符合合同约定的保险责任范围,故请求法院驳回原告的诉讼请求。
 江苏省淮安市淮安区人民法院一审查明:
 2009年7月30日,原、被告签订了保险合同一份,合同约定:险种名称为康宁终身保险合同(2007修订版),保费金额为2万元,保险期间为终身。康宁终身保险条款 (2007修订版)第五条第一款约定,被保险人于合同生效之日起180日后,初次发生本合同所指的重大疾病,本公司按基本保险金的二倍给付重大疾病保险。第二十三条重大疾病的名称及定义如下:“10主动脉手术指为治疗主动脉疾病,实际实施了开胸或开腹进行的切除、置换、修补病损主动脉血管的手术,主动脉指胸主动脉和腹主动脉,不包括胸主动脉和腹主动脉的分支血管,动脉内血管形成术不在保障范围内”。合同签订后,原告分别于2009年8月 1日、2010年8月10日缴纳保费共计 4600元,2011年2月12日,原告经淮安市第一人民医院确诊为主动脉夹层(Stan- fordB型),并建议转上级医院继续治疗。 2011年2月17日至2011年3月4日原告在江苏省人民医院行主动脉夹层覆膜支架隔绝术。原告要求被告给付保险金未果,遂诉至本院。
 2012年4月27日根据原告王玉国申请,委托了江苏省人民医院司法鉴定所对原告申请的“1.王玉国所患的主动脉夹层 (stanfordB型)是否属于主动脉疾病;2.主动脉夹层覆膜支架隔绝术是否比中国人寿保险股份有限公司康宁终身保险条款 (2007修订版)第23条第10款约定的开胸手术创伤更小、手术死亡率和并发症的发生率低;3.主动脉夹层覆膜支架隔绝术是否属于中国人寿保险股份有限公司康宁终身保险条款(2007修订版)第23条第10款约定的主动脉手术;4.患者的病情是否更加适合主动脉夹层覆膜支架隔绝术,是否属于主动脉修补范畴”等事项进行了鉴定,该所于2012年6月11日作出了省人医司鉴所法医临床[2012]鉴字第087号法医临床鉴定意见书,鉴定意见为:“王玉国所患的主动脉夹层(stanford B型)属于主动脉疾病;主动脉夹层覆膜支架隔绝术比中国人寿保险股份有限公司康宁终身保险条款(2007修订版)第23条第10款约定的开胸手术创伤更小、手术死亡率和并发症的发生率低;主动脉夹层覆膜支架隔绝术是主动脉手术,但其无需实施开胸进行;患者的病情更加适合主动脉夹层覆膜支架隔绝术,属于介入主动脉修补范畴”。2012年7月10日该所作出答复:“1.随着医学技术的进步,外科手术向微创化发展。许多原先需要开胸或开腹的手术,已被腔镜或介入手术所取代。被鉴定人王玉国所患疾病为主动脉夹层(stanford B型),该病患更适合用介入的方法行主动脉夹层覆膜支架隔绝术。对其实施的主动脉夹层覆膜支架隔绝术是主动脉手术,属于介入主动脉修补范畴,相对于传统的开胸手术,具有创伤小、死亡率低、并发症发生率低的优点,目前已取代了传统的开胸手术。2.对照委托方提供的中国人寿保险股份有限公司康宁终身保险条款(2007修订版)第23条第10款规定“主动脉手术指为治疗主动脉疾病,实际实施了开胸或开腹进行的切除、置换、修补病损主动脉血管的手术……”,被鉴定人接受的主动脉夹层覆膜支架隔绝术为主动脉手术,本术式与开胸手术虽途径不同,但目的一致,因其无需实施开胸,故创伤更小。本所用法医学及临床医学知识理解主动脉手术之本意为治疗主动脉疾病,治疗采用创伤小、死亡率低、并发症发生率低的方法为合理行为,新的术式取代旧的术式是科学的进步,具体手术途径非本条款的核心内容。3.本所鉴定主张已表达明确,本案矛盾焦点为保险条款滞后于目前医学技术所致”。原告支付鉴定费用5380元(检查费5280元、门诊费100元)。
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