Source: Beijing Business Today
On 10 month 12 day, the Supreme People's Court, the People's Bank of China, the National Financial Regulatory Administration, and the China Securities Regulatory Commission jointly released typical cases on protecting the legitimate rights and interests of financial consumers and investors.
Case 5: On 2020/9/11, Mr. X purchased a whole-life critical illness insurance policy with a rider for waiver of premium due to critical illness for his daughter, Ms. Wu, from a life insurance company. The basic sum insured is 40 ten thousand yuan, the annual premium is 4840 yuan, the payment term is 19 years, and the coverage period is for life. The insurance contract includes "Hepatolenticular Degeneration (Wilson's Disease)" within the scope of critical illness coverage but imposes multiple stringent clinical diagnostic requirements.
In 2024, month 2, Mr. Wu sought medical care at Children's Hospital of Zhejiang University School of Medicine due to abnormal liver function. Following multiple specialized examinations, he was diagnosed with "hepatolenticular degeneration (Wilson's disease)" on 2024, month 2, day 4. The hospital issued a "Certificate of Diagnosis" in accordance with legal requirements. Mr. Wu then filed a claim for critical illness benefits and requested premium waiver for subsequent installments with an insurance company. After review, the insurance company determined that although Mr. Wu's condition falls within the scope of critical illnesses listed in the contract, it did not fully meet all clinical criteria specified for this disease in the agreement. Consequently, the company denied both the benefit claim and the premium waiver request. Mr. Wu subsequently filed a lawsuit.
The People's Court of Quzhou Intelligent Manufacturing New District, Zhejiang Province, reviewed the case and found that the insurance coverage clauses in the disputed contract were standard terms provided by the insurer. These clauses impose stringent claim requirements, and the insurer failed to fulfill its obligation of adequate notification and explanation. Therefore, the insurer's refusal to pay is not well-founded. Continuing with litigation would necessitate expert appraisal, challenges to the appraisal findings, and review procedures, significantly prolonging the process. Given that Mr./Ms. Wu urgently needs the claim proceeds for ongoing treatment, the court prioritized mediation to promptly protect the parties' rights and resolve the dispute substantively.
Under court-mediated settlement, both parties voluntarily reached a mediation agreement on 2024/5/17: 1. A certain life insurance company shall pay Wu a one-time critical illness insurance claim payment of 36 ten thousand yuan;
II. Waiver of the 16th renewal premium of 4 yuan for Wu, effective from the date of diagnosis on 2024/2/4.
III. The personal insurance contract dispute between the plaintiff and the defendant is now concluded, with no further disputes between the parties. On 5/25, a life insurance company fulfilled its payment obligations. The case was resolved in just 20 days.
