健康保險理賠爭議案件之研究-以評議中心及法院判決之案例比較為中心

因全民健保的實施，國人平均壽命的延長，導致醫療費用的增加，對於商業健康保險的保障需求日增。但申請健康保險理賠卻時有爭議，縱使金融消費者至金融消費評議中心申請評議，其評議結果又可能與普通法院之判決結果不同。因此本研究以2015年至2019年間，財團法人金融消費評議中心前五大爭議案件類型：必要性醫療、失能等級認定、理賠金額認定、違反告知義務、投保時已患疾病或在妊娠中，查詢評議結果與法院判決不同之案例，分析理賠案件爭議原因。透過案例分析及整合研究，得出四項研究結果: 1.強化示範條款規範內容：增加「醫療必要性」定義、評估機能喪失及障害程度有關「症狀固定」及「立即可判定」的解釋、「疾病」發生的判斷原則。 2.訂定因應醫療技術進步之理賠原則：建議商品設計可多朝包含「給付限額」的方向。 3.理賠爭議案件之醫療判斷應有一致性規則：建議理賠爭議案件應有統一諮詢之醫療團隊。 4.遵守誠信原則，禁止權利濫用：針對個案得以民法第148條規定主張。

關鍵字

健康保險；理賠爭議；案例比較；醫療必要性；症狀固定；權利濫用

並列摘要

Due to the implementation of national health insurance, the average remaining life of the Chinese people has been extended, medical expenses have increased, and the demand for commercial health insurance has increased. However, there are disputes when applying for health insurance claims. Even if financial consumers apply for a review at the Financial Ombudsman Institution, the resolution may be different from the judgments of ordinary courts. The study is the comparison of the top five disputed types of the Financial Ombudsman Institution between 2015 and 2019：Medical Necessity, Determination of Disability Level, Determination of Claim Amount, Violation of The Duty of Disclosure, Preexisting Condition. Through case analysis, this study proposes four recommendations: 1.Strengthen the standard provision of health insurance: Add the definition of "medical necessity", the interpretation of "fixed symptoms" and "immediately determinable" in assessing the degree of functional loss and impairment, and the principle of determining the occurrence of "disease". 2.Set out the principle of claim settlement in response to the advancement of medical technology: It is recommended that the product design including the "payment limit" provision. 3.There should be consistent rules for medical judgments in dispute cases: It is recommended that a unified consultation medical team should be provided for dispute cases. 4.Comply with the principle of utmost good faith and prohibit the abuse of rights: For intentional tort case can be claimed in Article 148 of the Civil Law.