我國商業健康保險理賠爭議之探討

A Study On Claim Dispute Regarding Commerical Health Insurance in Taiwan Market

陳偉弘(Wei-Hung Chen)

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(2012年)

https://doi.org/10.6846/TKU.2012.00906

摘要

我國開辦商業健康保險商品至今逾四十年，消費者意識逐漸抬高，而保險糾紛也
隨之增加。依主管機關的統計資料，民國九十九年人身保險業的申訴案件共計3,092件，其中屬理賠糾紛的案件有1,339件，而健康險所佔的比例高達58.87%，居各險種之冠，實有檢討改善之必要。

理賠服務為保戶檢視評鑑一家保險公司的重要性指標之一，因保險商品屬無形性，僅於發生理賠時被保險人才能感受到其存在價值，理賠講求迅速性及正確性，目的在於一旦發生保險事故的時候，被保險人能夠迅速獲得賠償，不至使其經濟陷入困乏中。本研究主要係探討健康保險理賠爭議之問題，針對該險種的爭議案件予以分析及探討，可作為爾後保險公司處理糾紛或改進之參考，另期望可提供主管機關與相關單位(如檢警調司法單位、健保局…等)修法或是條款制定參考之依據。

關鍵字

商業健康保險 ； 理賠爭 ； 爭議類型

並列摘要

Taiwan has launched commercial health insurance products for
more than 40 years. As consumer awareness has gradually risen, insurance disputes have also increased.
According to the statistics released by the authorities, the life insurance industry had a total of 3,092 complaints in 2010, with 1,339 claim cases, and health insurance accounting for up to 58.87%, which held the highest rank among all insurances and was necessary to be reviewed and improved.

Claim service is one of important indicators for policyholders to evaluate an insurance company because insurance products are invisible and the values can be sensed by the insured only when incurring loss. Moreover, insurance claims emphasize promptness and accuracy for the purpose of which once the insured event occurs, the insured can receive financial compensation quickly instead of plunging into a deep crisis.

This research mainly discusses issues regarding health insurance claims, and analyzes and reviews the disputed cases, expecting to offer the information as reference not only to insurance companies for handling disputes or improving, but also to the authorities and relevant units (such as judicial inspection unit and Bureau of Health Insurance, etc.) for amending the Insurance Act or regulating clauses.

並列關鍵字

commerical health insurance ； claim dispute ； type of claims disputes

參考文獻

3.洪彰欣，我國癌症保險理賠爭議之研究，淡江大學保險學系保險經營碩士論文，民國九十七年一月。

4.許妙菁，人身保險理賠爭議之探討，淡江大學保險學系保險經營碩士論文，民國九十六年六月。

9.郭光泰，人身保險爭議解決制度之研究，淡江大學保險學系保險經營碩士論文，民國九十五年一月。

3.行政院衛生署，http://www.doh.gov.tw

5.行政院消費者保護委員會，http://www.cpc.gov.tw