**** must-know legal little common sense - high reaction leads to death · Insurance companies cannot refuse compensation
I. Background
Before I went to Xizang by car, I was just a cyclist who had long held the dream of self-driving, and I couldn't help but watch others ride on National Highway 219 or 318 for a long time.
Before the holiday in October last year, the new motorcycle had just arrived. Even the license plate delayed the self-release time. I couldn't wait to start from Shenzhen and go straight to the starting point of the Sichuan-Tibet Line in Ya'an, Sichuan. After clocking in, it passed through Daocheng, Deqin, Nyingchi, Sada, and then to Mount Everest. The whole journey lasted 6,4
00kilometers and lasted 25 days.
Before leaving, there was no support from the whole family. After all the good words of persuasion, they sent all kinds of frightening pictures and videos... Helplessly, I just finished watching "The Moon and Sixpence" and "The Fantasy Journey of a Shepherd Boy", and this time I'm sure: I only need my own sixpence.
Toughness is toughness, and responsibility is responsibility. For the sake of both, I still bought a lot of insurance for myself in advance before departure - driving safety can be careful, and high-reaction accidents have to be prevented.
II. Events
My own safety issues on the way are needless to say now. But I just came back from Xizang and heard something that made me feel terrified. At the same time last year, the cousin of a business school classmate was visiting Litang, where I passed by, and he suffered from altitude sickness. Before he could be delivered to the hospital, he was gone! More importantly, he also bought personal accident insurance, but the insurance company only refunded the insurance premium that had been paid.
III. Thinking
As a legal professional, my first reaction was that there must be a mistake.
For travelers to the plateau, the purpose of purchasing insurance before departure is to give their families and themselves a treatment or life protection after an accident. How could the insurance company just surrender the insurance after reporting the accident?
Fourth, follow-up
With the above questions in mind, I contacted the immediate family of the incident through my classmates.
After communicating directly with the family by phone, I found that: because the insured's insurance premium has been paid for 13 years, the family thought that the insurance company refunded nearly 80,000 yuan of insurance premiums as compensation!
I see...
The insurance company usually expressly stipulates in the insurance contract that if the company finally decides to refuse compensation, it must explain the reasons for the refusal in writing.
Therefore, I made an appointment for a family interview.
When asked why the insurance company refused to pay, the family members were confused - what is a refusal and when was it rejected?
It turned out that after the family members reported the case, the insurance company did not issue any legal documents such as refusing compensation, nor did it raise any topics related to the refusal of compensation with them. Because the family members did not know that they had been refused compensation, they had no sense of rights protection after being refused compensation.
The key is also: in order to collect the returned insurance premium "compensation" of nearly 80,000 yuan, the insurance company requires the family to cooperate and return all legal documents related to the claim, including the insurance policy, on the grounds of closing the case and filing. Now, if the family wants to protect their rights and provide evidence, they must first find a way, find a reason, and negotiate with the insurance company to get back the relevant insurance policy and other claim certificates.
I have to say that the above series of operations of the insurance company are really clever!
V. legal precedent
The preliminary understanding of the cause of the incident and the claim process further confirms my own previous legal judgment that the series of operations of the insurance company must hide mysteries!
With such curiosity, I used the "α coefficient" intelligent legal system developed by Mr. Hu Qingping's team to search for public legal precedents across the country. As a result, I really found multiple legal precedents for the same insurance company, the same insurance, and similar events.
Taking the personal insurance contract refusal dispute on plateau pulmonary edema in the Intermediate People's Court of Haidong City, Qinghai Province (2022) Qing02 Minjian No. 202 as an example, the legal precedent of such cases is: whether the insurance company should bear insurance liability for the death of the insured due to altitude sickness, that is, whether the death caused by altitude sickness is within the scope of compensation for accidental death?
(1) The concept of high altitude pulmonary edema
Pulmonary edema is not solely related to high altitude. If a person dies from pulmonary edema in a non-high altitude area, the cause of death is not classified as high altitude pulmonary edema, but should be determined according to the specific cause of pulmonary edema. And high altitude pulmonary edema is a special case of pulmonary edema, which is caused by rapid ascent to high altitudes (usually above 2500 meters above sea level) and failure to adapt to low oxygen environments.
(2) Reasons for the insurance company's refusal to pay
The cause of death of the insured is not caused by an accident, but by his own physical inadaptability to the plateau environment, resulting in his death due to altitude sickness. The cause of death belongs to the category of diseases, and altitude sickness is not an unforeseen risk, and it does not belong to the category of unforeseen accidents. It is not within the scope of compensation for personal accident insurance stipulated in the insurance contract. The insurance beneficiary's claim that altitude sickness is an accident is neither common sense nor legal basis.
(3) The court's interpretation of the insurance clause on the characteristics of "accidental injury"
1. From the perspective of the "externality" characteristics of accidental injuries
In medicine, it is generally believed that altitude sickness refers to the symptoms of hypoxia caused by the low pressure and low oxygen environment in the plateau area above 3,000 meters above sea level. It is caused by the external environment of the human body directly acting on the human body, causing the human body to suffer. The injury occurs under specific conditions and cannot occur without exposure to a specific environment. The damage to the human body becomes an inducing factor, with the characteristics of accidental injury "externality";
2. Judging from the "sudden" and "non-disease" characteristics of accidental injuries
According to daily experience, most people will foresee the possibility of altitude sickness when traveling to high-altitude areas such as Xizang, but altitude sickness does not necessarily occur due to individual differences, and the degree of physical damage caused by your mileage may vary. If there is no special or obvious disease in the body, the insured generally cannot foresee that altitude sickness will inevitably lead to serious physical injury or even death.
If the insurance company does not provide evidence to prove that the insured suffered from related diseases before going to the plateau, and I know that going to the plateau area will cause serious consequences such as damage or even death to his body, the insured's death due to altitude sickness during the plateau activities will have the characteristics of accidental injury "sudden" and "non-disease".
3. Judging from the "involuntary" or "unintentional" characteristics of accidental injuries
The reason why the insured needs to sign a personal accident insurance contract with the insurer is to ensure that his own interests can be compensated and protected in the event of an accident. Whether there is an accident should be judged and measured by the cognitive standard of ordinary people. Even if the insured has prior knowledge of the risk of altitude sickness when going to the plateau area, it cannot deny the characteristics of "unintentional" and "involuntary" death caused by altitude sickness.
In summary, the death of the insured due to altitude sickness fully meets the appearance characteristics of "accidental injury" as defined in the insurance clause. Therefore, the reason for the insurance company to claim that altitude sickness belongs to the category of diseases, not unforeseen accidents, cannot be established.
(Iv) Legal basis
According to Article 498 of the Civil Code of the People's Republic of China: If there is a dispute over the understanding of the standard clause, it shall be interpreted in accordance with the usual understanding. If there are two or more interpretations of the standard clause, an interpretation that is not conducive to the party providing the standard clause shall be made.
According to Article 30 of the Insurance Law of the People's Republic of China: In an insurance contract concluded with standard terms provided by the insurer, if the insurer disputes the terms of the contract with the policyholder, the insured or the beneficiary, it shall be interpreted in accordance with the usual understanding. If there are two or more interpretations of the contract terms, the people's court shall make an interpretation in favor of the insured and the beneficiary.
Although the above content is summarized from the legal precedent of individual cases, the legal analysis and judgment results of similar cases in different provinces and cities are basically the same, which has strong guiding significance. In addition, the above Litang Plateau Pulmonary Edema Refusal Case has been accepted and filed by the Futian District People's Court of Shenzhen after the evidence is reinforced. Please warn about the relevant trial results.
6. Suggestions for future travelers planning to come to Xizang, Qinghai and other highland areas
(A) grasp of insurance products
Not all personal injury insurance will cover high anti-accident. Therefore, when purchasing travel insurance before going to the plateau, you need to read the insurance terms carefully to understand the compensation conditions of the insurance products for altitude sickness, and avoid the occurrence of "wrong goods".
(2) Gatekeeping of evidence collection
Not all sickness or death caused by altitude sickness will necessarily be compensated. A lawsuit is a lawsuit - the beneficiary should clearly inform the institution or individual who made the evidence in the process of collecting evidence of danger, so as to avoid being rejected because the evidence record is wrong or unknown.
For example, if the written record of the death certificate provided by the beneficiary only states "death caused by pulmonary edema" instead of "death caused by high altitude pulmonary edema", or if there are similar written records such as "death caused by disease" and "death caused by various diseases" in the reason for the cancellation of the household registration, the probability of being rejected by the insurance company will be greatly increased.
Only by selecting insurance products and collecting all kinds of evidence in accordance with claims requirements can we truly avoid possible economic losses in the event of misfortune.
Around May this year, I planned to set out again, all the way west, before the rainy season, to enjoy the long-awaited Xizang and the spring flowers in Xinjiang, maybe wandering in the fields of Nepal, or maybe the mountain villages and alleys of Bhutan... The boat died, and Jiang Hai sent it for the rest of his life.
Author: Lawyer Guo Xiangfeng
Editors: Li Yuanyuan, Wang Ting
Typesetting: Li Jing, Zhiheng Cultural and Propaganda Department
Guo Xiangfeng Execution + Insurance Claims Team
February 28, 2024
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