□ Whether heatstroke is considered an "accidental injury" or a "disease" and whether to pay for it is mainly based on the insurance contract.
But sometimes "accidental injury" and "illness" can affect each other, making the distinction difficult or controversial.
□ When formulating insurance clauses, insurance companies shall make as detailed agreements and definitions as possible on the reasons for exemption and the concepts involved in the insurance clauses, so as to avoid unfavorable legal consequences in the event of disputes.
In the past few days, the high temperature weather has caused workers to suffer from heat stroke in many places.
Is heat stroke a "disease" or an "accidental injury"?
Should the insurance company pay for accident insurance?
Recently, a case released by the Shanghai Financial Court has attracted attention.
Master Li, an employee of a shipbuilding enterprise, died of heatstroke while working in hot weather.
The company had previously purchased accident insurance for it.
After the accident, the insurance company did not compensate for the heat stroke as a "disease" agreed upon as an exemption from liability, but Master Li's family believed that heat stroke should be an "accidental injury", so they appealed to the insurance company to pay the insurance money.
The first-instance court ruled that the insurance company should pay 400,000 yuan in insurance premiums. The insurance company refused to accept it and filed an appeal.
In the above cases, the focus of the insurance industry and insurance consumers is whether heat stroke is a "disease" or an "accidental injury".
In this regard, interviewed industry insiders believe that whether heatstroke is a "disease" or an "accidental injury" depends on the specific situation and cannot be generalized.
Li Wenzhong, deputy director of the Insurance Department of Capital University of Economics and Business, said that "accidents" in accident insurance refer to external, unintended, unpredictable or sudden situations.
In contrast, heatstroke satisfies the first two conditions, but it is difficult to meet the third condition.
Therefore, heat stroke in ordinary production and life should not be "accidental injury". Of course, the determination needs to be combined with the specific circumstances of the case, and some special circumstances should be identified as "accidental injury".
The presiding judge of the above-mentioned case, Yao Jingyan, believes that heat stroke caused by non-underlying diseases conforms to the characteristics of "accidental injury".
Chinese laws and regulations do not clearly stipulate the definition of "accidental injury".
The insurance contract involved in the case defines "accidental injury" as "injury to the body caused by external, sudden, unintended and non-disease objective events as direct and independent reasons".
In this case, there is no evidence to prove that the death of Master Li's heatstroke was caused by his own disease and the high temperature working environment. Therefore, it can be determined that Master Li's heatstroke was entirely caused by external factors such as high temperature, which is in line with the accidental injury that is external, sudden and unintended. The characteristics are also consistent with the insurable interests expected by both parties when the insurance contract is concluded, and do not exceed the scope of the insurance contract.
Wang Min, a senior consultant at Shanghai Jianwei Law Firm, agrees with Yao Jingyan's point of view.
He said that whether heatstroke counts as "accidental injury" or "disease" depends on specific issues.
In the above cases, the proximate cause of death from heat stroke should be determined based on the principle of proximate cause of insurance. If the proximate cause is an underlying disease, then the compensation should be included in the category of “disease”; if the proximate cause is high temperature, and it meets the characteristics of accidental injury , it is classified as "accidental injury".
Guo Yutao, a partner at Beijing Gefeng Law Firm, said: "Whether heatstroke is considered an 'accidental injury' or a 'disease' and whether or not to pay for it is mainly based on the insurance contract. But sometimes 'accidental injury' and 'disease' can affect each other, and it is difficult or difficult to distinguish between them. Disputes. And in disputed cases, the court will usually interpret in favor of the insured.”
Yao Jingyan said that in this case, the insurance contract did not clearly stipulate the connotation and extension of "disease". In the event of disputes between the parties on the content of the insurance clause, according to the provisions of Article 30 of the Insurance Law of the People's Republic of China , an explanation should be made in favor of the insured and the beneficiary.
In this regard, Wang Min suggested that in addition to further clarifying the exclusions, insurance companies should also perform the obligation of reminding consumers in accordance with the law when they apply for insurance, otherwise the exclusions may not take effect.
Yao Jingyan also said that when an insurance company formulates an insurance clause, it should make as detailed an agreement and definition as possible on the exemptions in the insurance clause and the concepts involved, so as to avoid unfavorable legal consequences in the event of a dispute.
Su Xianggao