| Summary: | 碩士 === 國立高雄大學 === 法律學系碩士班 === 107 === "The forensic doctors have already selected the accident option on the death certificate. How can the insurance company refuse to pay such claim?" This is often heard in the media about the accusation against the insurance company. In fact, the insurance accidental incidents are different from the forensic accidents or unexpected sudden death. Unexpected sudden death shall be translated as "unexpected death suddenly" and in accordance with forensic medicine and medical explanations, such as "sudden unexpected death caused by acute illness" are recognized as an accident by forensic doctors. In short, the death is "unexpected" and is not just an accident caused by external force. The insurance "accident" is determined by whether the accidental incident itself is an accidental incident covered by the insurance policy, and it is not determined by the selected type of death on the death certificate.
The claims disputes of accident insurance are mostly on the identification of accidental incident. According to the definition under the provisions of accident insurance policy, the accidental incident refers to "external accidents not caused by diseases". There is a case happened before that the cancer patient has prescribed the traditional Chinese medicines containing heavy metals in long term and later died from the chronic poisoning. Although such poisoning caused by the prescription of Chinese medicine was an external accident, the chronic poisoning is not a "sudden" situation. Hence, it is not covered by the accident insurance.
The occurrence of accidental incidents is not caused by one single reason. For example, the head hits the ground and there is an onset of stroke or other incident, and then is it a "disease" or an "accident"? The position of family members taken directly sees the results that there is a trauma, such trauma is caused by “accident” naturally. However, from the position of insurance company, it is naturally suspected that it will fall to the ground because of the onset of the disease, and of course it will be identified as a "disease" incident. The differences between the opinions of two sides often initiate the court proceedings, and it is hoping that the court can obtain a more detailed medical appraisal report to clarify such fact. The revision of the policy model clause has added the complexity of the identification, and the practice has not completely solved the problem of accidental identification. Regard to the court cases, there are still similar cases with different judgments, and even the Supreme Court does not provide a unitary opinion on such issues. Hence, the dispute cannot be resolved. In the face of these problems, in addition to maintaining the current theory of insurance law as much as possible, the existence of unfairness, the resolution method shall be found.
There are roughly three research methods in this paper; first, literature analysis method: collect the literature that will be analyzed and summarized. Second, the case study method: Explore practical cases and explore practical disputes through the theory of causation and burden of proof. Third, the method of legal interpretation: Sometimes there is ambiguous on the wording of the legal regulation under civil law, and taking the wordings too literally is not necessary to represent the original intention of the legislators. It is necessary to interpret the law.
The following is the structure of this paper. Chapter I is the introduction. Chapter II attempts to define the definition and characteristics of accident insurance and summarizes the accident insurance policy. Chapter III is to investigate the content and identification of accidental incident, and to summarize and analyze the elements of accidental incident provided the academics and practical cases. Chapter IV discusses the analysis of various causation theory, the legal interpretation of the current regulations, and the actual case as samples for the comparison and discussion hereunder. Chapter V is based on Chapter IV to clarify the meaning and legal basis of the burden of proof and also to discuss such matter based on the cases under the court practice. Based on such research, whether there are disputes and legal loopholes is discussed. Chapter VI summarizes various types of cases which are compared and analyzed with aforesaid studies and practices. Furthermore, Chapter VII makes the conclusions and suggestion.
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