Sino-Singapore Jingwei, June 8 (Wei Wei) Recently, some Shanghai residents reported that they were refused compensation for purchasing "isolation insurance" on the grounds that there were no medium and high-risk areas in Shanghai, which once again brought isolation insurance to the forefront.
Under the new crown pneumonia epidemic, various insurance companies have also taken the initiative to expand the insurance liability of accident insurance, and isolation allowances have become a new selling point. These accident insurances with isolation allowances are also called "isolation insurance".
However, recently, this insurance has been questioned by policyholders due to the difficulty in claim settlement. Some insurance companies refuse to pay for various reasons such as materials that do not meet the requirements of the clauses and need to be isolated in a centralized manner.
Industry insiders believe that complaints caused by isolation insurance are also a lesson for the insurance industry. For emergencies and epidemics, it is necessary to carefully determine rates and pricing, and rationally and objectively publicize and introduce product liability.
At the same time, insurance companies should pay more attention to special insurance products with certain social responsibilities and properly handle disputes.
A family of three is quarantined, why are some people being compensated and others being rejected?
How hot it used to be, how embarrassing it is now.
"I'm pressing many customers now, and I haven't asked them to submit claims, because the epidemic prevention policies and quarantine certificate templates are different in different places, and the insurance company's claims review standards and requirements are also a bit confusing. According to the previous claims experience, most customers use existing materials to submit If you go up, you will be rejected." Recently, Li Lan (pseudonym), an insurance broker, was worried about the isolation insurance sold.
She has customers in Beijing, Shanghai, Harbin and other places who have purchased isolation insurance from multiple insurance companies, but she did not expect that various problems would arise when claiming.
"Most of the customer quarantine certificates in Shanghai are self-applied through the application mini-program
. There is no specific quarantine reason written on the certificate, nor is the prevention and control measures written about mandatory home quarantine, but home health monitoring, which is not in line with insurance. The company’s claims for isolation allowances
are generally rejected, so I didn’t let customers upload the claims materials.” Li Lan told Sino-Singapore Jingwei that because Shanghai has just resumed work, customers who meet the requirements for claim settlement are now asking them to contact the local neighborhood committee. Reopen the certificate.
Not only are insurance brokers embarrassed, but policyholders are also struggling to settle claims.
Ms. Lan, the insured, told Sino-Singapore Jingwei that in February this year, she insured her parents and sister in Qitaihe City, Heilongjiang Province, with the "Worry-free Insurance" of Zhonghui Property Mutual Insurance Society (hereinafter referred to as Zhonghui Insurance).
Ms. Lan said that in March this year, her family received a phone call from the neighborhood committee and the Sub-district Office, because big data showed that Ms. Lan's parents and sister were close contacts, and asked them to go home quickly.
After returning home, the entire unit building where Ms. Lan's parents lived and her residence were sealed, and all three of them were required to be isolated at home.
After the quarantine ended, Ms. Lan collected all the materials and uploaded them to the insurance company's WeChat public account.
"About two weeks later, the result of the claim settlement came out. My mother and sister's insurance had been closed, and they received 1,600 yuan and 1,400 yuan in compensation respectively, but my father was refused compensation," Ms. Lan said.
Ms. Lan said that the reason for the refusal of compensation given by the customer service was that Harbin’s epidemic prevention policy was close contact and centralized isolation was required.
"My account book has been uploaded. Qitaihe City is different from Harbin City.
Besides, three people are isolated together. Why can't my father make a claim? Does the claim standard depend on the mood of the claimant?
" Ms. Lan said.
And Ms. Gao from Xi'an City, Shaanxi Province suffered multiple rejections by the insurance company.
In March this year, Ms. Gao took out the "isolation insurance" of Zhonghui Insurance.
On April 8, the community informed her that she needed to be quarantined at home for 14 days because she had been to Mengjia Village.
From 12:00 on April 10th, Mengjia Village was adjusted to a medium-risk area.
After the quarantine ended, Ms. Gao uploaded the materials, and it didn't take long to show that she was refused compensation.
Later, Ms. Gao contacted the customer service of the insurance company, "At first she told me that the reason for the refusal was that the materials were too vague, so I uploaded it again, and later said that the format of the uploaded materials was wrong, and the quarantine notice needed to use their company's template. I went to the community to open the certificate and stamp it again according to the template, and then the staff reported that there was a problem with my isolation application. Then another person said that I would be quarantined in a centralized manner when I came back from a medium-high-risk area, but the community only asked me to isolate at home. , I asked the other party to take out the relevant documents, but he couldn't take it out."
Ms. Gao said that after the above reasons could not convince her, the staff added that Mengjia Village was listed as a medium-risk area after she was quarantined, and it did not count as having been to a medium-high-risk area.
"I think the other party is just picking words. My colleague is in the same situation as me, but I bought products from other insurance companies, and the compensation has been paid."
Ms. Gao said that she had complained to the local China Banking and Insurance Regulatory Bureau, and then the supervision was given. I asked her the contact information of a staff member, and the other party said that she had reported the situation to her superiors.
Ms. He from Xi'an had a similar experience.
Ms. He told Sino-Singapore Jingwei that on April 17, she received a call from the relevant epidemic prevention department in Xi'an and was identified as a close contact person.
On the same day, she was sent to a hotel for isolation.
"I was quarantined at the hotel for 7 days, and at home for another 7 days, for a total of 14 days," Ms. He said.
After the quarantine ended, she filed a claim.
A few working days later, Ms. He found that her submission page showed "Case closed", and she also received a text message from Zhonghui Insurance, saying that it did not meet the insurance terms.
"I called the manual customer service and asked why the other party refused to pay the case. The
customer service said that one page of the materials I submitted was not clearly written and asked me to report the case again, but I found that the page could not be opened at all, and it was a blank page when I opened it, and I couldn't re-apply at all.
” said Ms. Ho
.
Insurance companies respond
According to the insurance policies provided by the three respondents, all three of them purchased the "Worry-free" insurance product of Zhonghui Insurance, with a premium of 59 yuan per year.
Sino-Singapore Jingwei sees on the electronic policy that the insurance liability of this product includes, in addition to accidental injury death and disability insurance benefits, sudden death insurance benefits, and new coronavirus pneumonia insurance benefits, etc., also includes new coronavirus pneumonia compulsory isolation allowance, insurance The amount is 200 yuan per day, up to 60 days, each time up to 30 days, and up to 2 times during the insurance period.
Article 9 of the "special agreement" in the policy shows that during the insurance period, the insured shall be subject to the following two situations, and the government at all levels, health and health commissions at all levels, streets, management committees and other national administrations approved by the insurer shall A notice from the government agency or the competent health agency of the relevant department entrusted by the health administrative department of the State Council (but the materials issued by the property management company and the community and other agencies will not be recognized), requiring to go to the designated centralized isolation point or to be required to implement compulsory isolation at home, insurance According to the insurance contract, people will be paid 200 yuan / day of new crown centralized isolation allowance.
There are two situations that trigger the isolation allowance:
one is that the insured person is required to be quarantined by the local epidemic prevention department because he is traced by the local epidemic prevention department as a close contact of a confirmed or suspected patient of new coronary pneumonia; the other is the place where the insured lives or works. , the travel route or destination is determined by the country as a medium-high risk area, and the local epidemic prevention department requires mandatory isolation.
The relevant person in charge of Zhonghui Insurance responded to Sino-Singapore Jingwei that, first of all, for claims related to the epidemic, Zhonghui will stick to the agreement of the insurance contract and abide by the insurance terms. This is also the social responsibility, insurance obligation and legal responsibility that an insurance company should have.
Secondly, the person in charge explained that
due to the different anti-epidemic policies in different places, in the process of claim settlement, users may submit some proof materials that do not meet the company's claim settlement requirements and conditions
. If the materials do not meet the claim conditions and the claim is rejected, there will also be corresponding text messages and explanations, so that the customer can clearly find out why the claim has not been paid or what materials need to be supplemented.
As of press time, the above-mentioned person in charge stated that all three policyholders have arranged exclusive claims customer service personnel to handle the case, and Ms. Gao's report has been handled properly.
In the case of the other two policyholders, the claims adjuster will investigate the situation in the community where they are located, and then further communicate with the customer.
Ms. Gao told Sino-Singapore Jingwei that she had been contacted by a claims adjuster and said that the materials would be re-examined. The other party had called the community to verify the matter, and said that the isolation allowance may arrive in the account in two days.
Insurance innovation must also take into account risks
Previously, many insurance companies have launched accident insurance that expands liability related to new coronary pneumonia.
On the one hand, the insurance is favored by policyholders, attracting a large number of policyholders for insurance companies;
With the increase of policyholders and underwriting risks, "isolation insurance" once rose in premiums, excluding epidemic areas from the coverage, and even from mid-March this year, many insurance companies removed "isolation insurance" from the shelves.
Talking about the reasons for the continuous disputes over "isolation insurance" claims, Dong Dengxin, director of the Institute of Finance and Securities at Wuhan University of Science and Technology, pointed out in an interview with Sino-Singapore Jingwei that it was mainly due to loopholes in the insurance clauses.
He believes that the
insurance clauses should make the coverage and payment conditions as clear as possible without ambiguity. At the same time, the information of both parties should be symmetrical
.
If the consumer cannot accept the reason for the refusal due to the unclear explanation of the terms, then the insurance company should bear certain responsibility.
Wang Deyi, a lawyer from Beijing Xunzhen Law Firm, analyzed Sino-Singapore Jingwei that China has confirmed in its legislation that the interpretation of insurance contracts applies the principle of unfavorable interpretation. If the insured, the insured or the beneficiary has a dispute over the terms of the contract, it shall be interpreted according to the common understanding. If there are two or more interpretations of the contract terms, the
people's court or arbitration institution shall make an interpretation that is beneficial to the insured and the beneficiary
. "
Wang Deyi believes that insurance companies should give special reminders to the insured when setting the conditions for refusing claims.
At the same time, the insurance company's refusal to claim cannot go against common sense and common sense.
He pointed out that in practice, many people are required to be quarantined without obtaining written documents from relevant government departments, and relevant written evidence is difficult to obtain.
Insurance companies cannot ignore these actual conditions and require the insured to provide stricter written evidence.
In Wang Deyi's view, the principle of substance over form should be adhered to. If the insured cannot provide written quarantine documents, other evidences (such as community transfer notices, the process of boarding, the actual trajectory of activities under quarantine, etc.) can be used to prove The actual situation of being quarantined, the above evidence should also be accepted.
Phenomena such as false propaganda and difficulty in settlement of "isolation insurance" have also attracted regulatory attention.
In January this year, the P&C Insurance Department of the China Banking and Insurance Regulatory Commission issued the "Urgent Notice on Issues Concerning Regulating the Operation of "Separation" Allowance Insurance Businesses to all CBIRC offices and property insurance companies, requiring insurance companies to fully comply with the instructions in the product sales process. It shall fully explain the insurance liability, liability exemption and claims settlement conditions, and make prompts and explanations on the clauses exempting the insurer from liability in accordance with laws and regulations that are sufficient to attract the insured's attention.
On May 30, the China Insurance Association issued the "Notice of the China Insurance Industry Association on the P&C Insurance Industry's Solid Promotion of the Implementation of Various Policies to Stabilize the Economy" to the property and casualty insurance industry, requiring all property and casualty insurance companies to continuously strengthen and improve quarantine insurance and other epidemic-related insurance Claim settlement work, improve the efficiency of claims settlement, and realize all claims within the scope of the contract.
A green channel for claim settlement has been opened for areas severely affected by the epidemic, so that claims should be paid quickly.
"This incident is also a lesson for the insurance industry," Dong Dengxin said in an analysis. The insurance rate depends on the probability of an accident, but in the event of an emergency or an epidemic, the probability of its occurrence is difficult to determine. Therefore, as an insurance company, its R&D risks are very high, and insurance product rates and pricing issues need to be carefully considered.
In addition, Dong Dengxin emphasized that insurance companies should pay more attention to special insurance products with certain social responsibilities and properly handle disputes.
(Sino-Singapore Jingwei APP)