人身保險理賠爭議之探討

A Study of Claim Disputation in Taiwan Life Insurance Industry

許妙菁(Miao-Ching Hsu)

指導教授 ： 郝充仁 ； 李雅婷

淡江大學/商學院/保險學系保險經營碩士在職專班/碩士(2007年)

https://doi.org/10.6846/TKU.2007.00265

摘要

在消費者意識抬頭之際，保險糾紛日益增多，由主管機關人身保險申訴統計觀之，民國八十五年人身保險申訴僅474件，惟經過十年的進展，民國九十五年人身保險申訴已達1644件，人身保險申訴案件成長約3.5倍。雖然部分人身保險理賠爭議係由要保人或被保險人惡意行為所導致，惟大多數的人身保險理賠爭議，常因保戶取得資訊不足或錯誤所導致，例如保戶不知如何填寫要保書、業務員告知錯誤觀念、保戶保險觀念不足、意外傷害事故認知差異、條款解釋錯誤等情形，除此之外，保險公司限縮解釋條款約定的承保範圍、對於除外責任的免責事由未詳加舉證、因保戶就醫浮濫就認定為非必要性醫療、核保時未詳查保戶就醫記錄等，皆為人身保險理賠爭議產生的原因。
保險公司申訴案件的多寡及申訴率，常是社會大眾拿來評斷或檢視保險公司良莠的指標之一，分析人身保險申訴案例，可瞭解保險公司理賠有無失當、保戶申訴原因、雙方主張落差、條款設計問題、未來潛在的理賠爭議‥‥等。本研究主要係藉由人身保險申訴案例探討理賠爭議之問題，分析導致人身保險理賠爭議之原因，並研究人身保險理賠爭議相關問題，期能藉由人身保險理賠爭議之分析與建議，提供主管機關、保險公司、業務員及消費者之參考。

關鍵字

理賠爭議 ； 保險申訴 ； 申訴案例

並列摘要

Nowadays, in view of the enhancement of the consumer consciousness, the claim disputations are getting more and more. Pursuant to the life insurance complaint statistics done by the Controlling Organization, the number of the complaint cases of life insurance was 474 in 1996 and, right after ten years, it had risen to 1,644 in 2006, a rapid growth of approximate 3.5 times.

Although some of the claim disputations of life insurance result from the malicious behaviors of the applicants and the insureds, the majority are owing to the insureds’ insufficient or misleading comprehensions, such as the insureds cannot correctly fill in application; the life solicitors convey wrong message; the applicants or the insureds do not have adequate insurance concepts, different understandings about the interpretations of the accidental injury and the misunderstandings about the clause wordings. Furthermore, the life insurers confine the insurance coverage, and do not present detailed evidences to the exclusion liability, and exclude the medical reimbursements due to the boasting applications by the applicants/the insureds as well as do not thoroughly underwrite the insureds’ past medical records, which are also the reasons to cause the claim disputations.

The insureds usually judge or inspect the quality of the insurance company by means of the quantity and the frequency of complaint cases raised. At the same time, a detailed analysis of the complaint cases of life insurance enables people to fully understand whether the settlement is proper, the reasons of the complaints, the allegation difference between the insurers and the insureds, the design problems of the clauses and the potentially claim disputations in future etc.

Through the research of the complaint cases of the life insurance, the study analyzes the causes of the claim disputations and other relevant problems. In the meantime, it also proposes the analysis results and practical suggestions, which should be helpful references to the Controlling Organization, the life insurers, the life solicitors and the consumers.

並列關鍵字

claim disputation ； the complaint cases of insurance

參考文獻

6.傅建承，壽險業保險犯罪實務之研究，淡江大學保險學系保險經營碩士在職專班碩士論文，民國九十六年一月。

3.李立文，保險百科，金錢文化企業股份有限公司，民國八十六年八月初版。

2.行政院消費者保護委員會 http://www.cpc.gov.tw/

5.許靜雯，壽險業務員之特質與保戶申訴之關聯性分析，淡江大學保險學系保險經營碩士在職專班碩士論文，民國九十四年六月。

5.Robert I. Mehr,Emerson Cammack and Terry Rose, Principles of Insurance.