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买了女性防癌险半年后得乳腺癌遭拒赔,法院判保险公司赔十万
2020-01-07 23:58   来源:  www.myviphealth.com   评论:0 点击:

买了女性防癌险半年后得乳腺癌遭拒赔,法院判保险公司赔十万2020年1月6日,杭州市中级人民法院公众号发布一

2020年1月6日,杭州市中级人民法院公众号发布一则“防癌险遭拒赔”案例。投保女性健康险后身患乳腺癌的王女士申请理赔时,收到了拒赔通知书,后将保险公司告上法庭。法院认为,保险公司利用格式条款排除王女士的主要权利,判决其赔偿王女士10万元、住院津贴2000元与相应利息。

On January 6,2020, the Hangzhou Intermediate People's Court issued a case of \"cancer risk rejection \". Ms. Wang, who has breast cancer after insuranceing women's health insurance, received a notice of refusal and took the insurance company to court. The court held that the insurance company used the form clause to exclude Ms. Wang's main rights and ruled that it compensated Ms. Wang 100,000 yuan, hospitalization allowance 2000 yuan and corresponding interest.

杭州市西湖区人民法院相关裁判文书显示,2018年3月,王女士通过代理人在保险公司处为自己投保魅力女性卡保险1份,保险责任为“意外身故20万,乳腺癌10万,其他妇科癌8万,女性生殖系统恶性肿瘤住院津贴100元/天,保费为385元,保险期限为1年”,王女士当场通过微信向代理人支付了保费385元,代理人向王女士确认投保成功。

According to the relevant judgment documents of Hangzhou Xihu District people's Court, in March 2018, Ms. Wang insured her charm female card insurance for herself through an agent in the insurance company, the insurance liability was \"accidental death 200,000, breast cancer 100,000, other gynecological cancer 80,000, female reproductive system malignant tumor hospitalization allowance 100 yuan \/ day, insurance premium 385 yuan, insurance period 1 year \", Ms. Wang paid the insurance premium 385 yuan to the agent through WeChat, the agent confirmed the success of the insurance to Ms. Wang.

2018年9月,王女士被确诊为(右乳)乳腺中级别导管内癌,医院建议切除整个右乳。10月,王女士在医院接受了切除手术,期间共住院20天。

In September 2018, Ms. Wang was diagnosed with (right breast) mid-grade intraductal cancer of the mammary gland, and the hospital recommended removing the entire right breast. In october, ms. wang underwent surgery in hospital for a total of 20 days.

手术后,王女士向保险公司申请理赔,然而,保险公司于2018年11月2日出具拒赔通知书,认为王女士所患属于原位癌,未达到给付条件,拒绝支付保险金。

After the operation, Ms. Wang applied to the insurance company to settle the claim, however, the insurance company issued a notice of refusal on November 2,2018, thinking that Ms. Wang's suffering from cancer in situ, did not meet the conditions of payment, and refused to pay the insurance premium.

2019年2月,王女士在西湖法院向保险公司提起诉讼。她表示,自己仅40岁出头,切除乳房给其带来了巨大的身心痛苦,被告拒不履行合同义务的行为使她的处境雪上加霜。

In February 2019, Ms. Wang filed a lawsuit against the insurance company in the West Lake Court. She said she was in her early 40s when she had her breasts removed and that the defendant's refusal to honour her contractual obligations added to her situation.

同时,该保险最显著的保障之一就是“乳腺癌”,对于一般的投保人,并不明确“乳腺癌”与“原位癌”的差异,保险公司所谓的“原位癌”也没有在医学中被广泛采纳,医疗机构确认王女士患有“右乳腺癌”,应当在该保险保障范围之内。

At the same time, one of the most prominent insurance guarantees is \"breast cancer.\" For the general insured, the difference between\" breast cancer \"and\" carcinoma in situ \"is not clear, and what insurance companies call\" carcinoma in situ \"is not widely accepted in medicine.

被告保险公司答辩称,原位癌不算真正的癌症,且王女士投保页面中明确保险责任范围“2.乳腺癌保险…上述乳腺癌不包括原位癌”。王女士所患疾病属原位癌,不在保险责任范围内,因此不应支付保险金。

The defendant's insurance company replied that cancer in situ is not a real cancer, and Ms. Wang's insurance page clearly defined the scope of insurance liability \"2. breast cancer insurance... the above mentioned breast cancer does not include orthotopic cancer \". Ms. Wang's disease is cancer in situ and is not covered by the insurance liability, so she should not pay the insurance premium.

法院经审理认为,保险公司以对于何为原位癌,原位癌与其承保的癌症有何区别,投保人所患疾病是否属于原位癌的解释权归属等问题,在王女士投保时均未向其解释、说明。且投保人投保案涉险种的目的就是缓解患癌之后巨额医疗费的资金压力,而该免责条款系格式条款,排除了王女士的主要权利,故该免责条款无效。

The court heard that insurance companies did not explain to ms. wang at the time of the insurance policy on what constituted carcinoma in situ, what was the difference between carcinoma in situ and the cancer they had insured, and whether the insured person's disease was a right of interpretation for carcinoma in situ. And the purpose of the insured is to relieve the pressure of the huge medical expenses after the cancer, and the exemption clause is the form clause, which excludes the main rights of Ms. Wang, so the exemption clause is invalid.

经西湖法院一审和杭州中院二审,最终判决该保险公司支付王女士保险金10万元和相应住院津贴,并赔偿利息损失。

After the first instance of the West Lake Court and the second instance of the Hangzhou Intermediate people's Court, the insurance company was finally judged to pay Ms. Wang's insurance premium of 100,000 yuan and the corresponding hospitalization allowance, and to compensate for the loss of interest.


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