The Paper reporter Dai Yue
Recently, with the continuous optimization of epidemic prevention and control policies, insurance related to the new crown epidemic has also been adjusted accordingly.
The Paper (www.thepaper.cn) recently found out that a number of new crown insurance products that "you can apply for compensation after diagnosis" launched by the insurance company have been sold out or removed from the shelves. critical illness.
In addition, The Paper interviewed a number of insurance institutions and learned that those who have purchased new crown pneumonia insurance products before and within the insurance period can currently make claims, but they all need a diagnosis certificate issued by a medical institution, and antigen self-test results are generally not recognized by insurance companies .
At the moment when asymptomatic and mild symptoms are usually treated in isolation at home, policyholders may face difficulties in obtaining evidence when making claims. Some lawyers suggest that at this time, the "Civil Code" clause on the change of circumstances can be applied to change the terms of the contract, that is, patients should be allowed Get compensation if you get other evidence that can prove that you were infected.
Existing new crown-related insurance multi-insurance critical illness and critical illness
The Paper noticed that the previous sales included Shuidibao's new crown epidemic prevention insurance, Huatai Insurance's new crown epidemic protection insurance, Zijin Insurance's new crown epidemic insurance, Taiping Property Insurance Changwuyou and other new crown insurances that "can apply for compensation after diagnosis" Products are either sold out or discontinued.
The new crown insurance that is still on sale mainly covers critical illness and critical illness.
The Paper searched and found that on Ant's insurance agency platform, there is an insurance product underwritten by PICC Health called "Anxin Anti-epidemic Bao (including the new crown)" that is still on sale.
However, unlike many previous new crown insurances, this product only pays for severe and critically ill people-new crown severe/critical illness hospitalization allowance, with an insured amount of 100,000 yuan; infectious disease (including new crown) hospitalization (including square cabin) allowance 100 yuan/day.
The customer service staff of the insurance company told The Paper that after the 15-day waiting period expired, the insured person was diagnosed with a new type of coronavirus pneumonia and reached severe or critical severity according to the "Diagnosis and Treatment Plan for Novel Coronavirus Pneumonia" valid at the time of diagnosis. If a hospital or a designated infectious disease medical institution designated by the local health administrative department must be hospitalized, the company will pay the specific infectious disease severe hospitalization allowance medical insurance according to the basic insurance amount agreed in the contract, and the contract will be terminated at the same time.
At the same time, The Paper noticed that some insurance companies have expanded their existing products to increase the insurance liability for severe and critical cases of new coronary pneumonia.
According to the information on China Life’s official website, as early as February 2020, China Life had expanded the liability of its existing 31 long-term critical illness insurance products to cover the insurance liability for the diagnosis of new coronary pneumonia.
China Life Insurance staff told The Paper on December 16 that the number of insurance types that have been extended to include new crown pneumonia insurance liability has reached 51.
China Life said that new and old customers who have purchased the above-mentioned insurance products do not need to pay additional costs. During the period of validity of the extended liability, the company can be insured according to the insured 25% of the contract’s basic insurance amount (or insurance amount) at the time of the person’s diagnosis will be paid as a new crown pneumonia insurance premium, and each policy’s extended liability payment is limited to one time and the maximum is RMB 1 million, and the insurance liability of the original insurance contract remains unchanged.
Confirmed infection with Omicron, and the clinical classification is severe or critical illness, also falls within the scope of the extended liability of the above-mentioned insurance products.
Similar to China Life Insurance, Ping An Life Insurance of China has also expanded the responsibilities related to the new crown pneumonia for the 85 long-term disease insurances currently listed.
If the customer is diagnosed with new coronary pneumonia for the first time during the validity period of the extended liability and the clinical classification is severe or critical, the company will pay an additional insurance premium of 20% of the basic insurance amount of the disease insurance in the insurance contract (the cumulative upper limit is 500,000 yuan) , the insurance liability of the original insurance contract remains unchanged.
In addition, according to the Beijing Puhui Health Insurance project team, Beijing Puhui Health Insurance has also recently given the insured person a new crown virus protection responsibility.
According to the insurance plan, within the insurance period, it has been diagnosed as a new coronavirus infectious disease by a public hospital of the second level (including) or above in the territory of the People's Republic of China (excluding Hong Kong, Macau and Taiwan) or a designated hospital for the diagnosis and treatment of statutory infectious diseases designated by the Health and Health Commission For severe or critical cases (diagnosis criteria will be dynamically adjusted in real time according to the guidelines of the National Health and Medical Commission), the insurer will pay a one-time insurance premium of 20,000 yuan, and the insurance liability for the insured will be terminated.
The Paper noticed that on December 9, the Beijing Banking and Insurance Regulatory Bureau issued the "Notice on Strengthening Financial Support for Resumption of Work and Production Relevant Work", requiring insurance companies to speed up the development of insurance products related to the new crown virus infectious disease.
Accelerate the design and development of new coronavirus infectious disease-related liability insurance with inclusive prices and suitable for a wide range of people to protect the risks of severe illness, critical illness and death caused by the new coronavirus.
At the same time, improve the protection level of "Beijing Puhui Health Insurance" insured, support insurance institutions to expand product insurance liability without raising premium rates, and improve the ability to protect against severe illness, critical illness and death risks caused by the new crown virus.
After the previous new crown insurance products are off the shelves, how to settle the claim?
If the relevant new crown insurance products are removed from the shelves, can the insured who previously purchased the insurance still apply for a claim if they are diagnosed, and can the antigen self-test "two bars" be used as the basis for diagnosis?
On December 16, The Paper consulted a number of insurance institutions as policyholders.
The customer service staff of Shuidibao told Peng Mei News that to apply for a claim for the new crown pneumonia insurance of Shuidibao, it is necessary to submit an inspection report issued by a public hospital above the second level. The payment ratio is different for different degrees.” At the same time, it is also necessary to upload the report documents of all the examinations performed by the hospital on the patient.
The customer service staff said that positive antigen self-test results do not count.
The customer service staff of Huatai Insurance said that those who have purchased the company’s new crown pneumonia insurance before, if they are diagnosed, they need to submit a positive certificate for the diagnosis of new crown pneumonia, “requires the severity of ordinary type and above”, and lung imaging issued by public hospitals above the second level Relevant pathology reports and cases of pneumonia manifestations were seen.
Huatai Insurance staff also said, "If only the antigen self-test results are available, it may affect subsequent claims."
The customer service staff of Zijin Insurance also gave a similar answer. She said that people who have purchased Zijin Insurance's new crown pneumonia insurance need to report to the insurance company first after they are diagnosed.
It is necessary to provide a certificate issued by a disease prevention and control institution or a medical institution for suspected or confirmed infection of a notifiable infectious disease, and a certificate of centralized isolation treatment issued by a disease control or medical institution, and it is necessary to indicate what isolation treatment measures have been taken, "also A discharge summary is required, and if there is no discharge summary, you can submit the diagnosis certificate on the first page of the case, inspection report and other materials."
Taiping Insurance has also launched the "Chang Wuyou" new crown pneumonia insurance product, and it is agreed that a confirmed diagnosis will receive an allowance of 20,000 yuan, and hospitalization and isolation allowances will be 200 yuan per day.
On December 16, the customer service personnel of Taiping Insurance stated that the materials required for claim settlement must be informed by the claim personnel.
As of press time, the reporter has not received any contact from the claims personnel.
At the joint prevention and control press conference of the State Council on December 8, Wang Guiqiang, director of the Infectious Diseases Department of Peking University First Hospital, said that most people infected with the new coronavirus can be treated at home, and only a small number of infected people with serious underlying diseases may need treatment. See a doctor at a medical institution.
In other words, if a person infected with the new coronavirus does not go to a medical institution for treatment, he will not be able to obtain medical treatment information, and he will not be able to apply for a claim.
Ding Jinkun, a lawyer from Shanghai Dabang Law Firm, believes that under the current situation, insurance companies should appropriately relax the claims conditions.
He mentioned that the insured patients and the insurance company are in an insurance contract relationship.
Under normal circumstances, proof of infection with the new crown should be provided according to the contract to obtain compensation.
However, after the adjustment of the prevention and control policy, at present, mild cases are generally treated at home, which makes it difficult for patients to obtain evidence. If the original contract is continued, the result will be unfair to the patients.
At this time, the change of circumstances clause of the "Civil Code" can be applied to change the terms of the contract, that is, the patient should be allowed to obtain compensation if he obtains other evidence that can prove that he is infected.
Article 498 of the "Civil Code" stipulates: "If there is a dispute over the understanding of the standard terms, it shall be interpreted according to the common understanding. If there are two or more interpretations of the standard terms, an interpretation that is unfavorable to the party providing the standard terms shall be made. The standard terms and If the non-standard terms are inconsistent, the non-standard terms shall be adopted."
Xu Hao, a lawyer from Beijing Jingshi Law Firm, said in an interview with a reporter from Beijing Youth Daily that insurance companies cannot unilaterally raise the threshold for claim settlement and increase the difficulty for policyholders.
For example, requiring special nucleic acid positive test reports, chest CT reports, etc. are beyond the usual understanding and raise the threshold for claims.