保前疾病之認定與適用問題－以臺南地方法院103年保險字第18號民事判決評釋為中心

A Study of Recognition of Pre-Existing Condition and Its Application Issues: Focusing on the Civil Judgment Bao Sian No.18 (2014) of Tainan District Court

陳俊元(Chun-Yuan Chen)

《靜宜法學》 6期 (2017/12) Pp. 77-101

摘要

保險法第127條規定：「保險契約訂立時，被保險人已在疾病或妊娠情況中者，保險人對是項疾病或分娩，不負給付保險金額之責任。」本條在疾病之認定與適用上頗有爭議。在疾病的認定上，學說似乎已經有限縮保險法第127條之傾向，故對於疾病之認定應該審慎為之，以避免保險人不當脫免責任。對於第51條與第127條之關係，可認為兩者規範對象不同，各有其適用範圍。就立法論而言，可考慮進一步將追溯保險之要件明文化，以避免爭議。對健康保險而言，只要能適當掌握保險與疾病之範圍，似可考慮刪除第127條，更能避免與其他法條之混淆與衝突。

關鍵字

健康保險 ； 追溯保險 ； 等待期間 ； 疾病 ； 告知義務

並列摘要

The Article 127 of Insurance Act provides that: ＂If, at the time an insurance contract is entered into, the insured is already sick or pregnant, the insurer is not obligated to pay the insured amount for the sickness or pregnancy.＂ However, there are controversies about the definition of sickness and the application of this article. For recognition of sickness, recent arguments intend to narrow down the scope of sickness. This paper also argues that scrutinizing of sickness is required to prevent insurers avoiding their liability. Regarding the application relation of Article 51 and Article 127, this study agrees with the argument that they have different targets and scopes. For legislative policy, it is worth of consideration to codify the elements of retroactive insurance to avoid controversies. As for health insurance, deletion of Article 127 is recommended if the scope of insurance and sickness can be properly recognized, and this should be also helpful for avoiding the ambiguity and conflict with other articles.

並列關鍵字

health insurance ； retroactive insurance ； waiting periods ； sickness ； duty of disclosure