Refuse to pay plateau death compensation
Yuan, who lives in Xinjin County, Chengdu, Sichuan, is going to work with others in Duo Township, Nyima County, Tibet. Before departure, Yuan purchased an accident insurance from China Life Xinjin Branch, with an insurance amount of 6.5438+6 million yuan.
The weather is unpredictable. On the evening of April 24, 2016, Yuan came to Laiduo Township, Nima County. The next day, Yuan suffered from severe altitude sickness syndrome due to his inability to adapt to the hypoxic climate of the plateau. He died on the way to the county hospital for rescue at Laiduo Township Health Center.
Yuan’s family members believe that Yuan’s death due to altitude sickness was an accidental injury and the insurance company should pay 16,000 yuan.
The insurance company stated that Yuan traveled to Tibet from Chengdu on April 2, 2016, and stayed in Lhasa for more than 20 days without experiencing altitude sickness. It can be seen that Yuan died not because of altitude sickness, but because of altitude sickness.
In fact, there are not a few cases of "altitude sickness" caused by altitude sickness. A survey shows that about 30% of people entering Tibet may suffer from altitude sickness, and severe cases may develop pulmonary edema, cerebral edema and other altitude sickness. Casualties caused by altitude sickness also occur frequently.
It is understood that Zou, a 69-year-old retired teacher from Guangdong Province, died of cerebral infarction and hemorrhage due to altitude sickness while traveling in Jiuzhaigou in 2005. Zou's family also took the insurance company and travel agency involved in the case to court, demanding compensation of 6.5438+0.2 million yuan from the two defendants. At that time, the insurance company also refused to pay compensation on the grounds that altitude sickness was a disease and was not covered by accident insurance. However, the court twice ruled against the insurance company.
The definition of motivation is controversial.
Whether a death caused by altitude sickness is an accident has become a thorny issue for insurance companies.
Generally speaking, the accident mentioned in the insurance contract refers to an external, sudden, unintentional, non-disease, unforeseeable objective event, resulting in a direct and independent accident. cause of physical injury, disability or death.
Guo, a partner at Beijing Gefeng Law Firm, believes that there are actually two issues that need to be resolved in this case. First, whether the death of the insured is an accident actually refers to whether it constitutes an insured accident; second, whether the death of the insured is due to altitude sickness actually refers to whether there is a deductible.
The reason why the insurance company refused to compensate was that altitude sickness is a disease. The definition of altitude sickness as altitude sickness is based on the "Internal Medicine" textbook published by People's Medical Publishing House, which states that "a group of diseases characterized by hypoxia caused by insufficient adaptability to the plateau environment is called altitude sickness."
The term "altitude sickness" is defined as acute altitude sickness, which is a natural physiological response of the human body to adapt to changes in air pressure, low oxygen content, dry air, etc. caused by altitude.
In this regard, Li Jiang, deputy general manager of Baowang, also believes that rapid pathological changes will occur under plateau hypoxia, causing complications such as pulmonary edema, coma, and heart disease. From a purely medical perspective, altitude sickness belongs to the category of disease. Insurance companies also generally believe that the insured's going to plateau is very likely to cause altitude sickness. In fact, it is foreseeable, so there is no need to pay accident insurance. This has become the insurance industry's standard for rejecting claims.
Regarding this case, many people in the industry question whether heat stroke and sudden death should also be included in the scope of compensation if altitude sickness is regarded as an accident insurance liability. What's more, considering that viral colds are also external, sudden, and unintentional, should they also be included in the scope of compensation for accident insurance?
Courts have decided differently.
For deaths caused by altitude sickness, the court ruled that insurance companies should pay different compensations.
The Xinjin Court of First Instance held that the objective fact that caused Yuan’s death was that Yuan entered a harsh plateau environment with thin air, reduced air pressure, and reduced oxygen content. The subsequent consequences were caused by objective events, such as altitude sickness. A generalized headache occurs; or a more serious situation occurs, such as difficulty breathing, and immediate rescue is required, or even death due to ineffective rescue or delay in time. Altitude sickness is only one of the direct consequences of this objective event. This objective fact fully meets the definition of accidental injury.
The Xinjin Court finally ruled that the insurance company should pay 16,000 yuan to Yuan’s family. The insurance company was dissatisfied and appealed to the Chengdu Intermediate Court.
The second instance of the Chengdu Intermediate People’s Court also held that according to the statements of the deceased’s family, Yuan’s physical health before the accident was “not hospitalized due to serious illness”, and the insurance company had no evidence to prove that Yuan was hospitalized due to his own internal diseases. To. Therefore, Yuan's death meets the definitions of "exogenous" and "non-disease", so Yuan's death falls under the definition of accidental injury and is an accidental injury death. For this reason, the Chengdu Intermediate People's Court upheld the original judgment.
However, some courts have rejected the claims of the insured's family members when encountering the above situation. For example, Zou, who is nearly seventy years old, has been informed by the travel agency that he may have altitude sickness, and he should be aware of this situation. The hospitalization certificate stated that the patient was diagnosed with right cerebral hemisphere infarction and died after resuscitation failed. The cause of death was cerebral infarction and hemorrhage, intracranial infection, lung infection, and respiratory failure. However, the family of the deceased failed to prove that Zou's death was an accident, so the lawsuit filed by his family was not supported.
High risk of specific diseases
In fact, altitude sickness is not covered by accident insurance for a long time.
Li Jiang suggested that in order to avoid the above situation, insurance companies should clearly exclude various complications caused by altitude sickness in their exclusions. When applying for insurance, the insured also needs to truthfully inform the destination and reason for travel.
Li Jiang said that insurance claims caused by altitude sickness actually exposed many problems, such as insurance companies simplifying complex clauses; insurance companies should widely educate and popularize insurance knowledge so that people can distinguish accidents (not accidents) in insurance clauses. (including disease) and the meaning understood in reality.
Industry insiders also remind that you need to purchase a specific type of altitude sickness insurance for work and travel. In this way, if an illness covered by the insurance policy occurs during plateau travel, the travel company and insurance company will bear the corresponding liability for compensation. .
Beijing Business Daily reporter learned from many insurance companies today that there are very few insurance companies and few products covering altitude sickness insurance caused by plateau travel. A Beijing Business Daily reporter called China Life customer service as a tourist today. The company’s customer service staff recommended buying accident insurance, but tourists traveling to plateau areas did not register it.
In 2009, PICC Health Insurance Company registered the "Plateau Specific Disease Medical Insurance" with the China Insurance Regulatory Commission, with a premium of RMB 88 covering a maximum total coverage of RMB 6.5438 million. However, according to relevant sources, the product channels are limited and can only be purchased through business personnel and counters. Each person can only purchase it once, and the coverage is limited to acute high altitude cerebral edema and pulmonary edema.
The relevant person in charge of the Northern Branch of Ping An Property & Casualty Insurance also said that altitude sickness itself is not an ordinary accident or acute disease, but a natural physiological reaction of people, so it is necessary to purchase insurance that specifically expands this kind of liability. Products, such as "domestic tourism-plateau tourism".
In this regard, Li Jiang said that plateau insurance has a high compensation ratio and insurance companies are unwilling to do it. If the premium increases, consumers will lack enthusiasm to buy. If only people working on plateaus will buy it, for insurance companies, this is a high-incidence, high-risk product that will undoubtedly lose money.
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