It is reported that some policyholders who have been infected with the new crown virus after being insured with new crown diagnosis insurance have fallen into the dilemma of strict claim materials, rejected claims or no one cares.

Mr. Sui of Shanghai has encountered a similar claim dilemma. He bought a new crown insurance for 2022 yuan in March 3, but when he was diagnosed with the new crown and went to the hospital, he was rejected by the insurance company on the grounds that "the diagnosis of the new crown virus is not the same as the diagnosis of new crown pneumonia". In February 69, Mr. Sui took the insurance company to court with a complaint. Recently, Mr. Sui successfully obtained a claim from the insurance company during the mediation stage.


Confirmed new crown >

However, the insurance company refused to pay on the grounds that it was "not pneumonia"

On March 2022, 3, Mr. Sui, who works in Shanghai, purchased a copy of the "New Coronary Pneumonia Quarantine Subsidy Version" underwritten by an insurance company and signed a contract.

The contract stipulates that the insurance period is "March 2022, 3 to March 11, 2023", and Article 3 of the contract clearly stipulates that "if the insured person has symptoms or signs of symptoms during the insurance period and is diagnosed with the new coronavirus (COVID-10 including the new coronavirus variant model) by a medical institution, the insurer will pay the confirmed insurance benefit according to the insurance amount agreed in this contract, and the insurance liability of the insurer shall be terminated".

On December 2022, 12, Mr. Sui developed symptoms related to the new crown and went to Shanghai Sixth People's Hospital for treatment, where he took a positive nucleic acid test. The disease certificate issued by the hospital reads: "It is hereby certified that the new coronavirus nucleic acid test is positive." Subsequently, Mr. Sui applied to the insurance company for a claim settlement and submitted relevant supporting materials in accordance with the requirements of the insurance company.

On February 2023, 2, Mr. Sui received an SMS notification from the insurance company indicating that the insurance company refused to settle the claim because it was "lacking the relevant diagnosis certificate issued by the medical institution and could not determine whether it was covered by this insurance product". On the same day, Mr. Sui received a call from the staff of the insurance company. The recording of the call provided by Mr. Sui shows that after the insurance company staff identified himself, he told Mr. Sui that he was infected with the "new coronavirus", but not "new coronavirus pneumonia", and the insurance product covered the situation of "pneumonia caused by the new coronavirus".

Mr. Sui's experience is not unique. It is reported that many consumers who have purchased new crown insurance have faced problems such as strict requirements for claim materials and denial of claims.

In February 2023, the China Consumers Association released the "Analysis of the Acceptance of Complaints by the National Consumer Association in 2", which pointed out that many consumers reported that with the surge in the number of infected people, they encountered various "high thresholds" in the "new crown" isolation and infection related insurance product claims, and some insurance companies refused to pay compensation on the grounds that consumers were diagnosed with "new crown virus infection" rather than "new crown pneumonia", playing "word games" for refusal.

The China Consumers Association reminds that according to Article 131 of the Insurance Law, insurance companies shall give conspicuous reminders and clear explanations to consumers of standard clauses that have a major interest in consumers, such as insurance liability, compensation standards, and deductible circumstances, and shall not deceive the policyholder, the insured or the beneficiary.


Keep intact evidence >

He took the insurance company to court and was awarded $15000,<>

Mr. Sui was once shaken and wanted to give up the claim, but with the help of his girlfriend Ms. Dong, who is engaged in the legal industry, he took the insurance company involved to court on February 2023, 2.

According to the ninth paragraph of the special agreement of the insurance policy provided by Mr. Sui, if the insured has symptoms or signs during the insurance period and is diagnosed with the new coronavirus (COVID-2 including the new coronavirus variant model) by the medical institution, the insurer will pay the confirmed insurance benefit according to the insurance amount agreed in this contract, and the insurance liability of the insured will be terminated.

Ms. Dong told reporters that the formal insurance policy does not stipulate that "pneumonia" must be paid in order to pay. According to relevant national policy documents, "new crown virus" and "new crown pneumonia" are just two statements of the same thing. "We insist that if the new crown is diagnosed, whether it is called pneumonia or whatever, there will be compensation if it is diagnosed."

On December 2022, 12, the National Health Commission issued an announcement to rename the novel coronavirus pneumonia to the new coronavirus infection.

Ms. Dong wrote in her complaint that Article 30 of the Insurance Law clearly stipulates: "In an insurance contract concluded using standard terms provided by the insurer, where the terms of the contract are disputed between the insurer and the applicant, the insured or the beneficiary, the terms of the contract shall be interpreted in accordance with the ordinary understanding." Where there are two or more interpretations of the terms of a contract, the people's court or arbitration institution shall make an interpretation favorable to the insured and the beneficiary. ”

"According to the common understanding of ordinary people, the insurance contract stipulates that the infection with the new crown virus, that is, the public generally known as 'Yang (sheep)', 'Recruited', 'infected (virus)', etc., is the common understanding of almost every Chinese, and the insurance company's attempt to violate common sense to interpret it as contracting new crown virus pneumonia is a serious violation of common sense." Therefore, the act of the insurance company seriously violated the provisions of Article 30 of the Insurance Law. Ms. Dong said.

According to reports, another major reason why the court accepted the case was that Mr. Sui retained the original evidence, which was submitted along with the complaint, as well as insurance policies, nucleic acid positive reports, medical cases, diagnostic certificates, blood test reports, lung imaging tests and other materials.

After the Shanghai Minhang District Court accepted the case, Mr. Sui said that he was contacted by the claims adjuster of the insurance company, and after several negotiations, the other party expressed his willingness to provide a claim of 15000,<> yuan.

Mr. Sui told reporters that after repeated weighing, he accepted the claim. "Although we are confident that we can get all 2,<> yuan in the trial, the process still drags on for a long time, and it will take a long time for the trial, and every day you remember and think about calling to negotiate, which is also very troublesome."

For other consumers who have difficulty in settling claims, Ms. Dong said that although it is troublesome to take the legal route, it is not difficult.

Chengdu Business Daily-Red Star News Reporter Chen Yifan Lan Jing Intern Xiong Siqi