Beware of the "second trial" of millions of medical insurance. The insurance company will refuse to pay after deducting the renewal premium, which is very annoying.

As we all know, insurance is to provide certain anti-risk ability for families and individuals when there is a risk of illness or accident. Ms. He of Shenyang has always thought so. She knows about commercial insurance and knows that there are some "pits" in critical illness insurance. Unexpectedly, she fell into another "pit" of millions of medical insurance.

On March 20 19, Ms. He bought millions of additional medical insurance in critical illness insurance for a family of three. As can be seen from the China life insurance contract provided by Ms. He, Ms. He purchased China life insurance whole life insurance, China life insurance plus China life insurance and China life insurance e Kangyue million medical insurance A from China life insurance company on March 27, 2009. The effective date of the contract is March 28th, 2009.

Insurance, to put it more complicated, is really complicated. Why? Because the insurance contract is particularly thick, there are many clauses in it, and the insurance is also very simple. Why?

As long as you are healthy and have passed the relevant procedures, as long as you pay this insurance, the next policy will take effect.

Most of us are afraid of trouble in life, and generally choose the second "simple" purchase strategy. After listening to the explanation of the business personnel, we pay for insurance and seldom study the original contract of the insurance policy carefully. This is because unexpected problems often occur in this case.

No one wants to use this insurance, but unfortunately, in June 2020, Ms. He's husband was hospitalized due to illness. According to Ms. He, her husband suddenly fainted for some reason, resulting in a cervical fracture, and then went to the Army General Hospital in Shenyang for treatment. The cost of treatment is about10.5 million.

654.38+0.5 million is not a small sum for any family. After her husband recovered, Ms. He came to China Life Insurance Company with her husband's insurance policy to make a normal claim.

Ms. He thought that she could reimburse these expenses, but unexpectedly she got an unexpected news. After waiting for about 20 days, the insurance company informed Ms. He that your insurance was rejected. The reason given by the insurance company is that Ms. He did not inform her husband that she had been hospitalized as early as June 20 19.

Ms. He said that her husband did have an examination and treatment in the hospital last year, but she didn't apply for compensation from the insurance company because the medical expenses could not meet the reimbursement standard of 65438+100000 deductible. She didn't think it was necessary to inform the insurance company about this situation. Unexpectedly, this has become the main reason why China Life Insurance Company refuses to pay.

Generally speaking, there is also a very important person in this case, that is, the salesperson of this policy. When selling this policy, whether the salesperson explained to Ms. He the protection responsibility of this medical insurance and how this million-dollar medical insurance was stipulated in this case played a decisive role in Ms. He's rights protection. But I never imagined that the insurance salesperson purchased by Ms. He was not others, but actually her own son.

Ms. He said that because her son had just joined China Life Insurance for less than a month, she had originally planned to buy insurance, and she also wanted to help her son.

However, although my son is a salesman, he has not fully understood the relevant terms of the contract because he just joined the company, so his son asked his "master" to introduce the contents of these insurance types to Ms. He.

Whether it is necessary to inform the insurance company of the million medical insurance within the validity period and whether the insurance company has the right to refuse to pay compensation. Ms. He and her son did not find the relevant terms. The son recalled that the company did not mention the training instructions of similar situations, and the "master" did not mention these contents when introducing this product.

Then the reporter contacted his son's master by phone and asked related questions:

Master: I really don't know the specific reason for refusing compensation.

Reporter: Then where can I get a definite answer? And did you tell her when you first promoted insurance that after the insurance came into effect, the insured had physical problems and needed to inform the insurance company?

Master: I didn't sell her this insurance, but her son sold it to her. I don't know about the subsequent insurance service.

Later, Ms. He said that she had been reporting the situation to the official customer service of China Life since the end of June this year, but so far she didn't fully understand why she was refused compensation. Ms. He thinks that I was in good health before I bought it, and I was insured after the insurance company finished underwriting, so I got sick later, so I don't need to tell the insurance company about my physical condition. Moreover, no one in the insurance company said that it is necessary to inform the insurance company if there is a headache, fever or hospitalization in the future; The insurance company has charged my premium this year.

In the afternoon, the reporter and Ms. He came to Shenyang Branch of China Life Insurance Co., Ltd., located at No.40 Fengyang Road, Sujiatun District.

It's a pity that the person in charge of the company went to a meeting in other places and was not received. At this time, Ms. He provided the reporter with the Notice of Refusal of Compensation issued by Shenyang Branch of China Life Insurance Co., Ltd. on September 2:

Why is it more and more difficult for insurance companies to sell now? Many people ridicule, some insurance companies are afraid of accidents, and some insurance companies are afraid that you will study. We won't be so happy when we find out that this joke has come true.

Let me briefly summarize the main process of this case:

From 2065438 to March 2009, Ms. He bought China Life Insurance's "China Life Xiangrui whole life insurance" plus "China Life Plus Xiangrui Pay Critical Illness Insurance in Advance" and "China E Kangyue Million Medical Insurance A" for her husband.

From 20 19 to 10, the insured was diagnosed as ankylosing spondylitis, osteoporosis, coronary heart disease and unstable angina pectoris, but did not apply for compensation from the insurance company because the treatment cost did not reach the deductible of 10000.

In June, 2020, the insured was hospitalized again, which cost 6.5438+0.5 million yuan.

June, 5438+October, 2020/KLOC-0 applied to China Life Insurance Company for claim settlement (million medical insurance liability). Because the insured was hospitalized in June 2065438+October 2009/KLOC-0, the contract was terminated (million medical insurance), and the insurance company refused to bear the hospitalization expenses and returned the premium paid in 2020.

Through the above cases, you may think that this is another case of "insurance companies playing hooligans". Judging from Ms. He's experience and rights protection experience, there are indeed problems such as "sloppy", "unclear responsibility for insurance introduction" and "unclear review of second medical insurance renewal". However, sometimes you can't just watch media clips or even unilaterally report scripts. You must know that as an influential person in society,

The insurance company's refusal to pay compensation has always been a hot topic with its own "soliciting customers" nature, which is naturally due to the "stubborn disease" accumulated by the insurance company itself for many years, as well as the "trap" of contract terms and some management problems, but there are also some social injustices, the most terrible of which is the "chaotic rhythm" of an influential institution like TV station. Why do I say that? I analyze this report from the following aspects:

From the very beginning, the media made a misleading mistake of an amateur guiding an expert. In fact, this is also an insurance misunderstanding that some of us will "think". This cognition is: whether you are healthy or not, as long as you pass the "audit" of the insurance company and pay the insurance premium, the insurance will take effect. Since the contract comes into effect, there is no reason for the insurance company to refuse to pay compensation on the grounds of past medical history, hospitalization or even what medicine you bought before insurance.

Seeing many people's comments on insurance claims disputes shows such a * * * view: since the insurance company did not investigate the physical condition of the insured before the insurance, it is equivalent to acknowledging the physical condition of the insured, and since it underwrites the insurance, it should fulfill the responsibility of paying for the later risks. Sorry, what we think of as "common sense" is a fundamentally wrong cognition here in insurance.

In the requirements of the insurance policy, if the necessary "physical examination" rules are not triggered (for example, the physical condition of the insured should be truthfully filled in according to the contents of the "health notice" in the contract), if the insured is dishonest or conceals the health condition of the insured, resulting in the dishonest evidence of the insured being investigated by the insurance company in the later stage, then the consequences of refusing to pay compensation will naturally be borne by the insured.

There are still many people here who will say that your insurance company should make an investigation before deciding whether to underwrite it. This is absurd for three reasons:

First, the insurance industry itself has a mature insurance process system, which will trigger different coping mechanisms according to the content of health notification. For example, in some cases, medical examination services will be provided if the future risks are not clear; Some conditions are not very good, and the underwriting results will be increased, postponed or exempted; From the experience of insurance companies, insurance will be directly refused in the case of high risk of claims in the future.

Second, the signing of the contract originally requires the insured to be honest and trustworthy. You play with your mind and abide by the insurance requirements of the insurance company, but let the insurance company directly investigate you? There is no problem with the investigation, and the insurance company should pay more for the investigation; If there is a problem with the investigation, the premium will not only be collected, but will also be posted backwards; Even if the insurance company can control the underwriting method in this way in the future, the cost will definitely be reflected in the premium, so the premium will definitely be more expensive in the future, and the extra cost will definitely be passed on to healthy people. Do you think this is reasonable?

Third, the insurance rules of insurance companies must meet the requirements of relevant laws and regulations. If you don't follow the rules of the game, forget it. Isn't it a bit unreasonable to break the rules of the game?

The reason why this report is a bit suspicious of "amateurs guiding experts" is because the insurance standards of insurance companies are wrong. The underwriting of insurance companies belongs to the system of "tracing" when accidents occur, which does not mean that insurance will be effective through the underwriting policy of insurance companies. The premise of the validity of the policy is that the customer has indeed fulfilled the obligation of "honesty and trustworthiness". If there is any concealment or deception,

What this report lacks is that customers refuse to pay when they are in danger, but only "complain" about the inaction of insurance companies, which is unfair in itself. If the customer has the fact of "insuring against illness", how can he finally become an influential news media organization? So I feel a little inappropriate, and then I will raise further questions.

According to the report, the key point of Ms. He's refusal to pay compensation this time is actually to ask "whether the insured's body changes first during the second year of renewal of millions of medical insurance will affect the insurance company's responsibility to fulfill its later payment obligations". However, it should be noted here that the type of disease described in the medical certificate of Ms. He's husband's previous hospitalization is very problematic.

Ms. He's husband was hospitalized in June 20 19, and was diagnosed as ankylosing spondylitis, osteoporosis, coronary heart disease and unstable angina pectoris. Anyone with a little life experience should know that none of these four diseases can be formed in a short period of time.

Ms. He insured her husband, but from 2065438 to March 2009, did she have related diseases before buying insurance, or did she just "stand up" and never go to the hospital for treatment? We don't know whether Ms. He has truthfully filled out the health notification. However, according to their own "big data" claims experience, as well as the causes and time of these diseases, the insurance company naturally has reason to suspect that Ms. He is suspected of "insuring diseases" for her husband, but the media did not say whether the insurance company has conclusive investigation evidence. We don't know. I just provide a hypothesis here.

Even if the insurance company has doubts, but there is not enough evidence to support it, it is obviously untenable to refuse compensation for this reason. Then let's assume that Ms. He's husband does meet the health notification at the time of insurance, and then let's take a look at the relevant renewal requirements of this million medical insurance.

Ms. He's husband applied for a serious illness claim, which shows that her illness does not meet the conditions for serious illness claim. However, since the treatment cost of10.5 million has been incurred, which exceeds the compensation condition of10.5 million, it is natural to apply for reimbursement of millions of medical insurance under normal circumstances, which is why I want to emphasize that the purchase of commercial insurance must be based on critical illness insurance+millions of medical insurance. however

The main focus of controversy in the report is whether the insurance company can terminate the contract alone due to the changes of the insured's health during the second-year renewal period of "China Life E Kangyue Million Medical Insurance A".

Many insurance customers have always been concerned about the renewal of millions of medical insurance. They are afraid that during the renewal period, their health will change, and insurance companies will no longer cover them, resulting in no medical insurance protection.

China Life's "China Life Insurance such as E Kangyue Million Medical Insurance A" was called "Super Social Security" when it was launched. What about the terms of its renewal?

According to Article 3 of the Contract, the specific terms of the insurance period and renewal are as follows:

This content is really professional, and it is also quite easy to avoid the important. I translated it into Chinese as follows: this million-dollar medical insurance is divided into two parts in time. The first part is the first insurance, which is valid for one year. The first year out of danger, compensation, terminate the contract; When the insurance is renewed for the second time, the health status of the insured can not change (including hospitalization, abnormal physical examination, medical insurance card to buy medicine) and pay the premium. After that, the insurance company will not refuse the applicant's application for renewal of insurance because of the insured's physical changes until the insured reaches the age of 80. Simply put, you can't get out of danger or have noticeable changes in your body in the first two years, otherwise you can't renew your insurance.

Therefore, the fundamental reason for Ms. He's husband's refusal to pay compensation is that the insurance company thinks that Ms. He's husband does not meet the requirements for the second renewal of insurance. Then the problem is coming. If this clause stands in the position of the insurance company, it may be correct, because one of the two conditions is not met, but what is the time point for the insurance company to review and agree? According to our ordinary people's understanding, it should be before the second insurance premium is charged. It is not clear whether our customers need to inform the insurance company of their physical changes, or whether the insurance company independently checks our customers' physical condition; From the customer's point of view, since the second premium is charged, it should be assumed that the insurance company's audit has been agreed, and it is natural to fulfill the responsibility of continuing protection.

There is great ambiguity in this. According to the requirements of relevant laws and regulations in China, since the contract is issued by an insurance company, the insurance company should bear the consequences caused by disputes or unclear interpretation of the terms of the contract. Then I think it is obviously unreasonable for the insurance company to directly refuse to pay compensation this time. The correct approach should be to pay the hospitalization-related expenses to Ms. He's husband as agreed, and then terminate the contract and no longer provide renewal.

In fact, this situation similar to Ms. He's "China Life E Kangyue Million Medical Insurance A" is not a case in the industry. Some customers who purchase this insurance cannot renew their insurance after the first year of insurance claims; There are also cases like Ms. He, who did not meet the claim conditions in the first year, but did stay in the hospital, or was diagnosed with chronic diseases such as hypertension and heart disease in the second year, and was refused insurance by the insurance company.

Not only does China Life Insurance's e- Conway Million Medical Insurance have such a "trap" of renewal, but AIA's smart choice of Conway Medical, Xinhua Life Insurance's gradual prosperity and Taikang Life Insurance's health enjoyment all require renewal in the second year, but we consumers can't fully know the "pit" inside, so a role is particularly important-insurance salesman.

No matter how beautiful the content of insurance protection is, there must be something that is not conducive to the rights and interests of our consumers. However, the insurance contract is very professional, and the terms are numerous and obscure, so it is obviously unrealistic to look at the contract by yourself. At this time, whether the salesperson has fully and necessarily explained and prompted the insurance we purchased directly determines the safety of our insurance use and the importance of how to safeguard rights in resolving disputes.

An experienced insurance agent, who is responsible to the customer, will definitely give special tips and explanations on the parts of the insurance contract that are unfavorable to our consumers, so that our consumers can understand the unfavorable factors. For example, in the case, if the insurance agent explained before and after Ms. He's purchase, whether it is critical illness insurance or millions of medical insurance, try not to go out or conduct unnecessary inspections in the first two years, or what adverse effects will be caused to our consumers in the first two years, then we will pay more attention to it ourselves.

If the insurance agent fails to fully explain and prompt the terms in our contract that are not conducive to our consumers, then the insurance agent will naturally bear the "main responsibility" for the settlement disputes caused by this. If the insurance agent can't afford it or has left his job, the insurance company will bear the relevant responsibilities. However, such disputes are usually resolved through civil litigation, so the relevant evidence obtained by agents is the decisive key to the success of rights protection.

Unfortunately, Ms. He's insurance agent is her own son. Although Ms. He's son stressed that it was his "master" who introduced the contents of insurance to Ms. He, Ms. He's son, after all, was the salesperson who made the most profit in sales, and naturally he had to bear the "main responsibility" for the incomplete interpretation of the insurance contract. If the self-protection part wants to safeguard its rights, it is difficult to safeguard its own interests. After all, the insurance sold by one's family will not be intentionally "subjective", and it is difficult for others to be "responsible" if they are "pitted" by one's own family.

Therefore, many insurance companies actually recruit "customers" in the name of recruiting insurance agents by "increasing staff", and some people are eager to "sell insurance for themselves" and save money by buying insurance.

However, insurance is a very professional industry, not an industry that simply thinks that you can do it by "understanding" the contract. Ms. He's son will not "hurt" her family, and I believe he can understand the terms of the contract, but why does this still happen? This shows that engaging in insurance work requires a certain amount of time and experience in addition to professionalism. It is difficult for a salesman who has not experienced many claims cases to find out how much impact these terms will have on the actual situation. You said you couldn't even understand your own story. How can you believe that he can serve customers well?

First of all, through the above description, whether Ms. He can finally get a claim depends on what the conditions are.

If the insurance company finds out that Ms. He's husband has relevant past medical history or abnormal medical examination or even evidence that the medical insurance card purchased relevant drugs before insurance, then it goes without saying that it must be a refund of the premium paid and a refusal to pay compensation.

If Ms. He doesn't have "sickness insurance", it depends on who is responsible for the settlement dispute caused by unclear contract terms. If the salesperson is not Ms. He's son, as long as there is evidence that the salesperson has not informed Ms. He of the relevant unfavorable terms, he can safeguard his own interests through negotiation, complaint and prosecution. The best result should be that the insurance company pays the hospitalization expenses, cancels the million-dollar medical insurance contract and no longer provides renewal services.

However, it is another matter that the salesperson is Ms. He's son, because the interests of the salesperson and the customer are the same. Who can guarantee that it was discussed by the same family? However, even so, they can still complain about rights protection, because the insurance company has charged the premium for the second year, which is regarded as that the insurance company has agreed to the customer's request for renewal.

In this case, it is obviously useless to negotiate with the insurance company. We can only complain through the CBRC or bring a lawsuit directly to the court, and let the insurance company bear the corresponding liability for compensation on the grounds that the insurance company collects the premium for the second year.

The final result is that Ms. He will definitely get the claim, but it is impossible to renew the million-dollar medical insurance.

I have always stressed that when buying commercial insurance, we must choose the combination of critical illness insurance and million medical insurance, so as to ensure that once the insurance fails to meet the standard of major illness claims, the extra million medical insurance can at least bear most of the high treatment costs. However, the million-dollar medical insurance is not without a "pit". For example, in this case, the million-dollar medical insurance purchased by Ms. He continued to be stored in the "second audit".

In fact, many millions of medical insurance that can be purchased separately basically do not have the problem of "second audit". It is not clear why China Life still has this multi-million medical insurance as the "main" supporting insurance.

Insurance contracts do have complicated clauses and many contents. If we don't pay attention to them, it is likely to harm the interests of our consumers. Do you think China Life brand is not big enough? Why is there such a problem? It can only be said that no one can change the product itself, but as an insurance salesperson, you should fully explain the terms that are unfavorable to you when selling insurance; As consumers, we also need to know that we should not only know what the purchase contract is about, but also know what is unfavorable to us or unfavorable to us.

Insurance is different from other commodities. If there is a big problem, don't replace it with something else, but insurance is different, especially millions of medical insurance. The body has changed, and it is worrying enough not to pay medical insurance. If we don't provide renewal service, we will have to bear the risk of hospitalization expenses in the future. None of us want to see such a thing happen. At present, you can't guarantee to meet an agent who is responsible for yourself, so more often, we consumers need to have the ability to "identify" ourselves, grasp the core defects of products, do more comparison and consultation when we are healthy, and don't be afraid of trouble, so as not to leave "future troubles" for ourselves, and it will be really late.