Is it a disease or an accidental damage? Should insurance companies pay?

□ Severing stroke is considered "accidental damage" or "disease" and whether to pay, mainly based on insurance contracts. However, sometimes "accidental damage" and "disease" can affect each other and distinguish between difficulty or controversy.

□ In the formulation of insurance clauses, insurance companies shall make as detailed agreements and definitions on the exemption of the insurance clauses and the concepts they involve in the insurance clauses, so as not to bear unfavorable legal consequences in the case of disputes.

The high temperature weather in the past few days has caused the heat strokes of workers in many places. Is heat stroke a "disease" or "accidental damage"? Should insurance companies pay after insurance accident insurance? Recently, a case released by the Shanghai Financial Court attracted attention.

Master Li, an employee of a shipbuilding company, died of heat stroke during high temperature weather. The company had previously insured it. After the incident, the insurance company was not compensated by the scheduled "disease" category agreed by heat stroke. However, Master Li's family members believed that heatstroke should be "accidental damage", so he asked the insurance company to pay insurance benefits. The court of first instance decided that the insurance company paid 400,000 yuan in insurance.

In the above cases, the focus of the insurance industry and insurance consumers pay attention to whether the heat stroke is "disease" or "accidental damage". In this regard, people interviewed by the industry believe that whether heatstroke is a "disease" or "accidental damage" depending on the specific situation, it cannot be generalized.

Li Wenzhong, deputy director of the Insurance Department of the University of Economic and Trade, said that the "accident" in accident insurance refers to foreign, unspeakable, unpredictable or sudden cases. In terms of comparison, heat stroke meets the first two conditions, but it is difficult to meet the third conditions. Therefore, the heat stroke in ordinary production and life should not be "accidental damage". Of course, it is determined that it is necessary to combine specific cases. In some special circumstances, it should be identified as "accidental damage".

Yao Jingyan, the trial judge of the above case, believes that the heat stroke caused by non -basic diseases is in line with the characteristics of "accidental damage". my country's laws and regulations do not make clear stipulation on the definition of "accidental injuries". The interpretation of the "accidental damage" involved in the case involved in the case is "the body's damage to the body is directly and individually and individually" by the objective event of an external, non -original, and non -disease objective event. " There is no evidence in this case that Master Li's heat stroke is caused by his own disease and high temperature working environment. The characteristics are also consistent with the insurance interests expected by the two parties when the insurance contract is established, and it does not exceed the scope of the shooting of the insurance contract.

Wang Min, a senior consultant of Shanghai Jianwei Law Firm, agrees with Yao Jingyan's point of view. He said that "accidental damage" of heat stroke or "disease" should be analyzed for specific problems. In the above cases, what should be based on the principle of insurance near the cause of insurance and judge the recent cause of heat stroke death. If the cause is the basic disease, then the payment should be included in the category of "disease"; It belongs to "accidental damage".

Guo Yutao, a partner of Beijing Gefeng Law Firm, believes: "Is the heat stroke be considered 'accidental damage' or the" illness' and whether they pay the payment, which are mainly based on insurance contracts. Disputes. In the case of controversy, the court usually explains the insured. "

Yao Jingyan said that in this case, the connotation and extension of the "disease" in this case have clearly stipulated the connotation and extension of the "disease". When the parties are controversial about the content of the insurance terms, in accordance with the provisions of Article 30 of the Insurance Law of the People's Republic of China It should be explained to the insurer and beneficiary.

In this regard, Wang Min suggested that in addition to further clarification of insurance companies, the insurance company should also perform the prompt obligation in accordance with the law when consumers' insurance insurance, otherwise the responsibility may not be effective.

Yao Jingyan also said that when formulating insurance clauses, insurance companies should make as detailed agreements and definitions on the exemption of the insurance clauses and the concepts involved in the insurance terms, so as to avoid unfavorable legal consequences in the situation of disputes.

(Source: Economic Daily)

【Edit: Shang Pei】

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