A man participating in an outdoor activity suffered a fracture, resulting in a tenth-level disability. He filed a claim with his insurance company, but the company refused to pay, arguing that he did not meet the “total disability” criteria specified in the insurance contract. How can he safeguard his rights and interests in this situation?
Case Background
In February 2024, Ran Mou purchased sports accident disability insurance from a certain insurance company to cover his participation in mountain bike sports. While cycling through the jungle, Ran had an accident, resulting in an injury to his left upper limb. After diagnosis by the hospital and appraisal by a judicial appraisal institution, Ran Mou suffered a proximal fracture of the left humerus, and the degree of disability caused by the injury was grade ten.
Ran Mou demanded that the insurance company pay the disability claim according to his disability level. However, the insurance company stated that the insurance contract stipulates that only when the insurer is “totally disabled” can the compensation be made. Since Ran Mou’s injury did not constitute a first-level disability, which is referred to as “total disability” in the contract, the insurance company refused to bear the disability compensation.
Legal Action and Court Ruling
To safeguard his legitimate rights and interests, Ran Mou took the insurance company to court, demanding that it bear the disability insurance benefit for sports accidents. The court ruled that the insurance company should pay Ran Mou over 110,000 yuan in compensation.
The court’s decision was based on the following findings:
Standard Terms and Lack of Clear Explanation: The insurance contract provided by the insurance company was a standard term. The company failed to provide legal and valid evidence to prove that it had clearly explained the concept of “total disability” at the time of insurance purchase. The term “total disability” only refers to the first-level disability listed in the “Standards and Codes for Disability Assessment of Personal Insurance” attached to the insurance contract. The insurance company should bear the consequences of failing to provide evidence.
Invalidity of Exemption Clauses: The court did not support the insurance company’s defense and claim that it would not pay the sports accident disability insurance money to Ran Mou. The court ruled that the insurance company should pay Ran Mou an insurance compensation of over 110,000 yuan. After the judgment, neither party appealed, and the judgment has come into effect.
Legal Insights and Recommendations
A judge from the Intermediate People’s Court of Wenshan Prefecture highlighted the following key points:
Obligation of Prompt and Explanation: During the insurance application process, insurance companies should fulfill the obligation of prompt, that is, for standard terms such as exemption clauses and claim conditions, they must be highlighted in bold, bold, or other prominent ways, and proactively explain their meanings and legal consequences. Otherwise, the relevant terms will be invalid.
Scientific and Reasonable Design of Insurance Terms: The design of insurance terms should be scientific and reasonable. Terms such as diagnostic criteria and exemption scope should keep pace with medical development to avoid setting lagging or unreasonable claim conditions.
For policyholders, it is essential to:
Read the Insurance Contract Carefully: Before taking out insurance, policyholders should read the insurance contract carefully, focusing on contents such as “exemption clauses,” “diagnostic criteria,” and “claim conditions,” especially those prominently marked in bold or bold. For professional terms or ambiguous expressions, the insurance company should be requested to provide a written explanation, make it clear and explicit, and keep communication records to avoid subsequent disputes.
Preserve Medical Evidence: Policyholders should also pay attention to keeping evidence of medical treatment. In case of an accident, they should promptly preserve medical records, diagnosis certificates, test reports, and other supporting materials, and ensure that the relevant certificates meet the formal requirements stipulated in the contract.
Relevant Legal Provisions
Article 496 of the Civil Code of the People’s Republic of China: A standard term is a term that a party has prepared in advance for repeated use and has not negotiated with the other party at the time of concluding a contract. Where a contract is concluded by using standard terms, the party providing the standard terms shall determine the rights and obligations between the parties in accordance with the principle of fairness, and adopt reasonable means to draw the other party’s attention to the terms that exempt or reduce its liability and other terms of significant interest to the other party. At the request of the other party, it shall explain such terms. Where the party providing the standard terms fai
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