Take the case to the risk
01 The gist of the case
Concealing the situation of the accident after taking out the insurance first is a case of false notification.
02 Case Introduction
Guangdong *** sales *** in September 2021 insured the insurance company's accident products, the preservation has 30 days retroactive. Zhang, an employee of the company, was admitted to the hospital on December 14, 2021 due to a fall injury**, and the medical expenses incurred were about 30,000 yuan, and he submitted a claim application to the insurance company in April 2022. After investigation, it was found that the insured Zhang had joined the insurance unit in August 2019, and in January 2022, the insurance unit submitted Zhang's application for additional insurance, and the effective time of the additional insurance was retroactive to December 6, 2021, and the insured personnel were not informed of the insurance situation. According to the conclusion of the investigation and the situation of the preservation application, Zhang is a new employee who has been insured after the accident and is not a new employee, so he does not meet the conditions for retroactive insurance of preservation. The insurance company refused to pay on the grounds that the additional insurance did not meet the retroactive conditions.
03 Case Analysis
In this case, Zhang was not a newly hired employee and did not meet the conditions for retroactive insurance reinsurance, and the insured unit did not truthfully inform the insured personnel of the insurance situation when the insurance was added, concealing the actual employment time of the employee. According to the agreement, after the policy takes effect, the new employee shall go through the procedures for adding and reducing the insurance within 30 days from the date of his entry and resignation, and the effective time of the insurance increase and reduction shall be subject to the date of entry and resignation, otherwise the effective date will be subject to the next day when the insured unit formally submits the information on the change of preservation and the insurance company reviews and approves. If the insured unit fails to correctly exercise the rights of the policyholder, fails to fulfill the obligation to truthfully inform, and applies for retroactive insurance after the accident, it is an adverse selection operation. The insurance company will not approve it.
04 Case Enlightenment
The insured unit shall carefully read the terms and conditions of the insurance when applying for insurance, shall fully understand the rights and obligations of both parties, exercise its legitimate rights within the scope agreed in the contract, and fulfill the obligation to inform truthfully.
For businesses with retroactive effective dates, the business line should fully communicate with the insured unit, correctly use the convenience granted by the insurer, fully understand the insurance situation of the insured unit, and avoid being unable to settle claims normally after the accident.
Contributed by: Jiangmen Central Branch).