In the practice of claims, insurance companies generally see cases involving liability exemption in the medical records, and most of them will issue a notice of refusal on this ground.
Is this kind of thinking that "I" want to refuse the compensation after looking at "your" medical records?
Around 2013, the insurer Li applied for a critical illness insurance in an insurance company, with a small hospital medical insurance attached.
You were hospitalized at a local hospital on August 17, 2023 due to illness**.
The main diagnosis is: atrial septal defect type ** (foramen ovale).
Other diagnoses were: hyperlipidemia, pulmonary nodules, cervical spondylosis.
On September 20, 2023, the insured received a notice of refusal, which reads: In view of the fact that the ** congenital disease in the existing cases is exempted from the liability of the clause), the company has decided not to accept the application for this benefit.
Obviously, this is unreasonable, and then I communicated with the insurance company again, and finally agreed to pay 3,000 yuan.
In this case, the insured's main diagnosis is: atrial septal defect type (foramen ovale type), and the disease** is: Q21101. The disease is indeed a congenital disease, but I think it is a hooligan to talk about claims regardless of responsibility, and the responsibilities in this include both terms and other responsibilities.
There are two problems with this:
1. Whether there is a detailed investigation before rejecting the claim to verify the entire insurance process;
2. Even if there is no problem with the insurance process, do the expenses other than congenital diseases in the medical record have to be calculated?
1. The investigation is to verify whether the insured has truthfully informed and whether the insurer has clearly stated before applying for insurance. In this case, the Insured only knew about this situation at the time of the incident, because congenital diseases can occur at birth or after birth, and it is obvious that this was not intentionally done by the customer, so there is no situation where the customer did not truthfully inform the customer.
As for the other insurance processes, it is difficult to explain this part of the situation until the insurance process can be retrospectively managed. However, I think that the insurance company should at least have a verification action, and if there is a certain problem with the insurance company, it must be the corresponding responsibility in this link. After all, *** put forward the famous thesis that "there is no right to speak without investigation" in "Against Essentialism"!
2. The issue of complete exemption and partial exemption is more common in this kind of situation, and if the result is completely caused by the factors that exempt the liability, the result is completely exempted; If the result is only partially caused by the liability factor, then the part that does not involve the liability should be handled normally. In this case, it is clear that the client's hospitalization falls into the latter category.
In summary, this case should be paid, because the insurance company cannot calculate the specific amount of compensation, so in the end, it can only be paid according to the amount agreed by both parties.
1. Many practitioners believe that the probability of claim settlement can be increased by "beautifying" medical records, in fact, it depends on the situation, if it is some subjective factors that are difficult to define (such as "chest pain" in acute myocardial infarction), then write according to the contract, which is indeed conducive to claims; However, the nature of the disease is not what the customer says in the medical record, but depends on the disease code and the doctor's opinion to decide.
2. Key points of the agreement: If the amount of compensation can be clarified, it is reasonable to pay according to the amount; If it is not possible to clarify the amount to be paid, it is necessary to negotiate, and the proportion of the part that falls within the scope of insurance liability in the whole event should be used as a reference.
3. Strictly speaking, the exemption of liability in an insurance contract does not only require reference to the liability exemption clause, but needs to meet three conditions: the setting of the exemption clause does not violate the relevant legal provisions and the principle of fairness and reasonableness, the insurer must clearly explain the exemption clause, and there must be a causal relationship between the exemption circumstances stipulated in the clause and the insured accident.
Note: Claims come from teammates!
Insurance denials